On June 21, 2011, the Departments of Justice and Health and Human Services (“HHS”) announced that Maria Haber, an owner of a medical clinic based in Metro Detroit, was sentenced for her involvement in a $1.12 million Medicare fraud scheme. Haber’s penalty includes 15 months in prison, 3 years of…
On June 17, 2011, the Centers for Medicare & Medicaid Services (“CMS”) announced that beginning July 1, 2011 it will start to utilize an innovative predictive modeling technology to aid the prevention of Medicare fraud. This CMS announcement comes in the wake of Obama’s Campaign to Cut Waste launch. The…
MedPAC released its highly anticipated proposal calling for a reduction in the use of imaging services, including MRIs, CT scans and nuclear medicine, and, in particular, recommended pre-authorization for medical imaging services as a means to accomplish this objective. The MedPAC report focuses, in particular, on physicians who order an…
In reviewing certain inpatient hospital claims, the RAC for Region B (covering the Midwestern states), CGI, and its subcontractor, PRG Schultz, are now requesting that nursing notes not be included in response to additional documentation requests (“ADRs”). Note that this directive is not consistent across all ADRs, as other ADRs…
In addition to the multitude of auditing activities and programs that exist, the Medicare Carriers/Medicare Administrative Contractors also conduct medical reviews. Like many other auditing programs, these probe reviews are data driven and are conducted for the purpose of validating potential provider billing errors. The process may include either provider…
A Florida radiology clinic, Midtown Imaging LLC, and its former owners–Midtown Imaging PA and PBC Medical Imaging–have agreed to pay $3 million to settle allegations that Midtown Imaging LLC submitted false claims to Medicare between 2000 and 2008. The allegations arose from Midtown Imaging LLC’s lease and professional services agreements…
June 7, 2011, the Departments of Justice and Health and Human Services (“HHS”) announced that Reynel Betancourt, a 51 year-old Miami resident, was sentenced for his involvement in a $9 million Medicare fraud scheme originating in metro Detroit. His penalty includes 77 months in prison and three years of supervised…
The Centers for Medicare & Medicaid Services (“CMS”) is taking steps in anticipation of its Medicare Part D RAC program release; this component of the RAC program is expected to begin in the third quarter of 2011. The director of the Medicare Program Integrity Group, John Spiegel, announced that CMS…
Gentiva Health Services, Inc. (Gentiva)–one of the largest providers of home health services in the world–has settled with the government for $12.5 million. The settlement came after allegations that it fraudulently billed Medicare for non-Medicare-covered costs. According to the Department of Justice Press Release, “[a]n investigation established that, through its…
On June 1, the Office of Inspector General (“OIG”), Department of Health & Human Services (“HHS”) announced expected recoveries of $3.4 billion from its legal actions (including investigations and other reviews, totaling about $3.2 billion) and audits (approximately $222 million). Most of the OIG reviews concerned Medicare and Medicaid. The…