Unnecessary Ambulance Services Speed Manager Towards Criminal Sentencing

Wesley Harlan Kingsbury, the general manager of a California ambulance company, pled guilty to conspiracy to commit Medicare fraud, conspiracy to obstruct a Medicare audit, and making materially false statements to law enforcement officers after he was charged for his involvement in a scheme to defraud Medicare. According to a Department of Justice (DOJ) press release, Kingsbury will be sentenced in February 2015, for his criminal involvement in the scheme that included the owners and the training supervisor of Alpha Ambulance Inc. (Alpha), all of whom have already been sentenced for their roles in the conspiracy.

Scheme

According to court documents, Kingsbury conspired with his coworkers to bill Medicare for ambulance services that Kingsbury knew to be unnecessary. The charges also alleged that Kingsbury used his position as a general manager to instruct emergency medical technicians (EMTs) who worked for Alpha to alter paperwork to conceal the true medical conditions of the individuals they fraudulently transported. After learning that Alpha was going to be subject to an audit, Kingsbury allegedly used light tracing tables to create and alter documents to send to Medicare, as well as shredded original documentation to conceal the fraud. In total, the scheme resulted in $5,522,079 in fraudulent claims to Medicare, $1,338,413 of which Medicare paid.

Lies

Kingsbury was approached by law enforcement and asked to help them in their investigation of Alpha. According to the DOJ release, Kingsbury told Alpha’s owners about law enforcement approaching him and told the company’s owners the names of the law enforcement officers, as well as the questions he was asked. When asked later, Kingsbury allegedly falsely denied to law enforcement that he had disclosed the information to Alpha’s owners.

Investigation

The case that was investigated by the Federal Bureau of Investigation (FBI) and the HHS Office of Inspector General (OIG) has already led to sentences of 75, 108, and 30 months for the two owners and the training supervisor of the ambulance company. The case is being celebrated as a success for the Health Care Fraud Prevention and Enforcement Team (HEAT), which, to date, has charged almost 2000 defendants for billing Medicare a collective $6 billion.

Kusserow’s Corner: OIG Reports Many States are Cheating the Federal Government by Inflating Federal Share of Medicaid

The HHS Office of Inspector General (OIG) has found that in addition to providers cheating federally-funded programs, so have many states. Since the Medicaid program was established, the costs and responsibilities for administering it have been shared between the states and the federal government, according to an established formula. The OIG has repeatedly found state policies that deliberately distort the cost-sharing arrangement through “loop holes,” causing the federal government to pay more than its share of Medicaid expenditures, without any benefit to beneficiaries.

Medicaid is a rapidly expanding program that provides health coverage for nearly 60 million Americans today. State policies that inflate federal costs for Medicaid are not a new trend; the OIG identified this issue in a series of reports from the early 2000s focusing on hospitals and nursing homes. These reports found numerous examples in which states developed creative funding mechanisms to apply money from intergovernmental transfers—between government entities—to the states’ share of Medicaid costs, thus driving up the amount the federal government would have to match. States transferred the additional federal Medicaid money to their general treasury funds to use for a range of purposes with no direct link to improving quality of care or increasing Medicaid services. In essence, the intergovernmental transfers reduced the states’ share of Medicaid costs and provided them with money to apply for whatever purposes they wanted by gaming the matching formula so the federal government would pay significantly more than its share. The OIG has seen numerous examples in which states then redirected that additional money for other purposes while medical facilities remain underfunded.

Although over the years CMS and Congress initiated a number of changes to close loopholes that have produced some improvements, other potential loopholes remain. The OIG cited many examples of gimmicks to transfer Medicaid costs to the federal share. Collectively, the findings of the OIG suggest a need for a definitive regulation linking Medicaid payments to the actual cost of service. For years, the OIG has recommended that CMS seek this legislative change to strengthen its ability to curb the wasteful federal spending that occurs when states claim reimbursement for excessive payments. One unsaid difficulty in seeking legislative action is that legislators from many of the states engaged in cheating the federal government are reluctant to close loopholes that will lead to their states having to bear the legitimate burden of their share of Medicaid. This in effect would add liability of billions of dollars to the state taxpayers, instead of the federal taxpayer. Many Congressmen and Senators are loathed to do that, even though it is the right thing to do.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2014 Strategic Management Services, LLC. Published with permission.

Kusserow’s Corner: HHS Provides Further Clarification for Certification of EHR

Health information technology (HIT) developers, providers and consumers will get more flexibility through a Final rule issued by the Office of the National Coordinator for HIT (ONC) at HHS.  The purpose of the ONC is to ensure that electronic health record (EHR) technologies meet the standards and certification criteria to allow providers and hospitals to achieve meaningful use and participate in the CMS EHR Incentive Programs. CMS manages the CMS EHR Incentive Programs and meaningful use. The CMS EHR Incentive Programs provide incentive payments to Eligible Professionals (EPs) and Eligible Hospitals (EHs) as they adopt certified EHRs and successfully achieve meaningful use. CMS establishes the meaningful use objectives and measures which EPs and EHs must achieve in order to qualify for incentive payments. The standards, implementation specifications, and certification criteria establish the minimum requirements that certified EHR technologies must include to support the achievement of these objectives and measures

The Office of Certification was established to develop and oversee national programs for the certification of health information technology by the HITECH Act. HIT certification provides assurance to purchasers and other users that an EHR system offers the necessary technological capability, functionality, and security to help them meet meaningful use objectives and measures.  Certification also gives providers and patients confidence that the HIT products and systems they use are secure and can work with other systems to share information (interoperability).

The Final rule is designed to add flexibility as well as clarity and improvements to the current 2014 Edition EHR certification criteria and the ONC HIT Certification Program through a new “release” of optional and revised criteria. In effect, the certification criteria and program updates included in the new release under the Final rule were proposed earlier this year; in response to public comments received, the Final rule provides alternative certification criteria and approaches for the voluntary certification of HIT.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on Google+ or LinkedIn.

Subscribe to the Kusserow’s Corner Newsletter

Copyright © 2014 Strategic Management Services, LLC. Published with permission.

SNFs Accused of Billing for Unnecessary Services Settle for $3.75 Million

Two skilled nursing facilities (SNFs) that were alleged to be involved in a scheme of billing and submitting claims for unnecessary and unreasonable rehabilitation services, executed a settlement agreed that stated it would pay $3.75 million to the government. Life Care Services, LLC (LCS) and Core Care V, LLP doing business as ParkVista (ParkVista), were reportedly accused of retaining RehabCare Group East, Inc. (RehabCare), to provide such services and of failing to prevent RehabCare’s “practices designed to inflate Medicare reimbursement.”

LCS and ParkVista

LCS is described by the Department of Justice (DOJ) as a manager of SNFs; it is located in Des Moines, Iowa. ParkVista is a SNF located in Fullerton, California. According to the DOJ, LCS operated ParkVista as well as an additional Massachusetts facility and that LCS suggested that the these facilities hire RehabCare and, in turn, caused ParkVista and the Massachusetts to submit the false claims created by improper billing practices.

Allegations

Specifically, the government accused LCS and ParkVista of several improper billing practices including: (1) presumptively placing patients in the highest reimbursement level of therapy without giving credence to each patient’s individualized evaluations showing their specific level of required care; (2) after placing patients in the highest reimbursement level of therapy, only providing the minimum number of minutes for that therapy and discouraging any therapy beyond that minimum time; (3) “arbitrarily shifting the number of minutes of planned therapy between therapy disciplines to ensure targeted reimbursement levels were achieved;” and (4) rounding and estimating minutes for reporting. In general, the government contended that these practices resulted in the submission of false claims to Medicare for unnecessary and unreasonable services.

Case Details

The case against LCS and ParkVista was handled by the U.S. Attorney’s Office for the District of Massachusetts and the DOJ Civil Division’s Commercial Litigation Branch as well as HHS, the HHS Office of Inspector General, and the FBI. According to the DOJ, the identification of the alleged wrongdoing in this matter and the subsequent settlement is a result of the efforts of the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which is part of a joint effort of the Attorney General and the Secretary of HHS. CMS Medicare fraud outreach materials note that HEAT was established to “build and strengthen existing programs combatting Medicare fraud while investing new resources and technology to prevent fraud and abuse.”