Miami Home Health Owner Gets 106 Months, Ordered to Pay $21M in Restitution

The U.S. Department of Justice (DOJ) announced that Ramon Regueira, the owner and operator of a Miami home health care agency (HHA), was sentenced to 106 months in prison for his participation in a $30 million Medicare fraud conspiracy. In addition to the prison sentence, Regueira, 66, of Miami, was ordered to pay $21 million in restitution, both jointly and severally with co-conspirators.

Plea Agreement

According to the DOJ, Regueira was an owner of Nation’s Best Care Home Health Corp. (Nation’s Best), a Miami HHA that purported to provide home health and therapy services to Medicare beneficiaries. Regueira admitted that from January 2007 through January 2011, he and his co-conspirators:

  • operated Nation’s Best for the purpose of billing the Medicare program for, among other things, expensive physical therapy and home health services that were not medically necessary or not provided;
  • paid kickbacks and bribes to patient recruiters who provided patients to Nation’s Best, as well as prescriptions, plans of care (POCs) and certifications for medically unnecessary therapy and home health services; and
  • used these prescriptions, POCs and medical certifications to fraudulently bill the Medicare program for unnecessary home health services.

Co-Conspirator

On September 26, 2013, the DOJ announced that co-conspirator Emilio Amador, 46, pleaded guilty to his involvement with fraudulent billings for Nation’s Best. Amador, who was an owner, operator, and the president of Nation’s Best, also received 106 months in prison and was ordered to pay restitution.

According to the DOJ, Nation’s Best submitted approximately $30 million in claims for HH services that were not medically necessary or not provided, and Medicare paid approximately $21 million for these fraudulent claims.

Kusserow on Compliance: 2014 OIG Year in Review

The HHS Office of Inspector General (OIG) posted  more than 35 podcasts to their website in 2014.  The latest podcast is a summary of their 2014 Year in Review that looked back at highlights of their activities.

  1. The OIG reported nearly $5 billion dollars in expected recoveries in fiscal year 2014. The recoveries resulted from program audits and investigations.
  2. The OIG reported 971 actions against individuals or entities that engaged in crimes against HHS programs as well as 533 civil actions during the fiscal year.
  3. Medicare Strike Force efforts by the OIG and its partners at the Department of Justice resulted in the filing of charges in 232 criminal actions.
  4. Six OIG Most Wanted fugitives were captured during the year.
  5. The OIG excluded more than 4,000 individuals and entities from participation in federal health care programs during 2014. Among them was pediatric dental management chain CSHM, for “repeated and flagrant violations” that put kids at risk.
  6. The OIG negotiated more than 40 corporate integrity agreements (CIAs), among them one with the Extendicare nursing home chain that alleged “effectively worthless care.” Extendicare agreed to pay $38 million dollars.
  7. The OIG found that, after Health Insurance Marketplaces first opened, they faced major challenges with inconsistencies in applicant data.
  8. In its report, Access to Care: Provider Availability in Medicaid Managed Care, the OIG found that slightly more than half of Medicaid managed care providers could not offer appointments to enrollees.
  9. The OIG testified at 10 hearings on Capitol Hill in 2014. You can read that testimony on the OIG website.

Other reports summarizing OIG activities in 2014 include its Semi-Annual Reports to Congress, OIG Work Plan, and OIG Budget Proposal.

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.

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Copyright © 2015 Strategic Management Services, LLC. Published with permission.

Burwell Extends Olive Branch to Congress on Everything but the ACA

Several potential areas of common ground between HHS and the new Republican-led Congress were discussed by HHS Secretary Sylvia Burwell at the New America Foundation. Although Burwell expressed an expectation that Congress and HHS could work together successfully on several issues—including Medicare, Medicaid, opioid abuse, Ebola, and drug development—Burwell made clear that she had no intention of backing away from her support of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148).

ACA

Burwell’s comments seemingly took discussions about the ACA off the table. Burwell said, “I also hope that we can move beyond the back and forth of the Affordable Care Act and focus on the substance of access, affordability and quality.” She expressed her opinion that “the law is working” and that she would continue to “be vigorous in making the case.” Burwell also encouraged states that have not yet expanded Medicaid under the ACA to join those that have.

Opioids

The HHS Secretary made several comments about the importance of addressing the growing problem of opioid abuse. Burwell’s remarks were premised on the understanding that opioid use and abuse is rising at record-breaking rates. She indicated that in 2012, 259 million opioid prescriptions were written—enough for every American adult to have a bottle. Similarly, in 2009 drug overdoses outnumbered car crash fatalities for the first time. To address the rising figures, Burwell called on Congress to address opioid prescription practices and to incentivize the production of abuse deterrent medications.

Ebola

Burwell thanked Congress for making efforts to stop the global Ebola crisis at its source. Specifically, Burwell commended Congress by responding to the Ebola crisis by investing $597 million towards global health security. She also lauded the efforts of the U.S. and other countries for working together to stop outbreaks like Ebola before they become pandemics.

Innovation

Another area that Burwell encouraged Congress to facilitate is innovation and science in medicine. She acknowledged that Congress itself was aware of the bipartisan need to accelerate and further innovations for vaccines, cures, therapies, and rapid diagnostics. Burwell placed particular emphasis on working with Congress to achieve more in the area of precision medicine, or diagnostic and treatment methods that are tailored to the individual and genetic characteristics of a patient.

Response

According to a story from Kaiser Health News, despite Burwell’s comments regarding a strong stance on the ACA, HHS can expect to work successfully with senators and representatives from both sides of the aisle. For example, Sen. Lamar Alexander (R-Tenn) said that “we have plenty we disagree on, but we also have plenty of issues that are important to millions of Americans upon which we should be able to get results, including, for example, getting life-saving drugs, treatments and devices through the FDA to patients faster; remodeling the health care delivery system; and improving global health security.”

Kusserow on Compliance: Statistical Sampling in OIG Reviews

On January 12, 2015, the HHS Office of Inspector General (OIG) released a Podcast explaining the statistical sampling that it performs. The presentation was by Lisa Wombles, Senior OIG, and Jared Smith, OIG Audit Statistician. It was noted at the outset that the OIG frequently uses statistical sampling as it provides the ability to cover thousands or even millions of claims in a fair and objective fashion. If the OIG did not use sampling methodology, it would have to review a majority of claims and with the large number of records involved, such reviews would make it much more difficult for providers to gather the necessary supporting documentation and appeal any contested claim. This type of review would not be efficient or cost effective for either the provider or the OIG.

Statistical sampling is applied to a variety of areas including hospitals, home health, physician services, and durable medical equipment. The OIG will always consider using sampling whenever it’s not possible to review every claim. Each review is viewed as unique, so the sampling method used in each review varies based on different risk factors. This way, the OIG applies the appropriate statistical formulas to calculate any estimated overpayment. It documents and keeps all documents and data related to every sample so that the review can be reproduced.

Regardless of the sample design used by the OIG, it employs an estimation method that gives the provider the benefit of the doubt for any uncertainty in the sampling process. The OIG professes that it uses overpayment estimates that will almost always be lower than what it would obtain from reviewing every claim. The OIG notes that courts have held that the methodology need not be precise or optimal as long as it is statistically valid. The OIG ensures that its work meets this standard by evaluating each sample using the appropriate law or regulation. Whatever method it employs must meet four standards:

  1. Statistically valid
  2. Efficient
  3. Produce a sample that’s representative of the larger group
  4. Produce a valid estimate of any overpayment

When the OIG looks at a sample of claims selected from a larger group of claims, it makes an estimate, but only applies the estimate to the specific larger group of claims from which the sample was drawn. It reduces the overpayment estimate in order to properly account for claims that are canceled, refunded to the Medicare program, or otherwise not in error. The OIG made it clear that if done properly, the process it employs creates an accurate and efficient way to look at a lot of data. It was specially noted that numerous administrative appeal decisions and federal court cases have concluded that statistical sampling is an appropriate way to calculate any overpayment. Courts and administrative hearings have also upheld the right of providers to appeal when the OIG uses statistical sampling to question costs or claims, or in appealing an individual determination of an overpayment through the normal Medicare appeals process.

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 on Compliance Newsletter

Copyright © 2015 Strategic Management Services, LLC. Published with permission.