Kusserow on Compliance: Is there no limit to fraud cases?

Doctor convicted in connection to a $325 million fraud case

Falsely diagnosing patients with lifelong illnesses

Needlessly subjected patients to unnecessary medications

A Texas rheumatologist was convicted in a jury trial in connection with a $325 million healthcare fraud case. He was found guilty of falsely diagnosing patients with lifelong illnesses and needlessly subjecting them to unnecessary medications such as chemotherapy drugs and then falsely billing insurers for millions of dollars. The DOJ saw this as an extremely egregious case because the doctor falsely diagnosed vulnerable patients—the young, elderly and disabled—with life-long diseases requiring invasive treatments that those patients did not in fact need.

The DOJ further noted that many of the patients, including one as young as 13, suffered physical and emotional harm as a result of the chemotherapy injections, hours’ long intravenous infusions, and other excessive, repetitive and profit-driven medical procedures. Also noted was that the evidence presented at trial showed that to obstruct and mislead a federal grand jury investigation, the doctor falsified medical records.

 

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 LinkedIn.

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Copyright © 202o Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: Not all data breaches are from accidents or cyber attacks

1,182 Beaumont Health patient records compromised

Employee passed patient information to a personal injury law firm

Undetected for 3 years

Not found by hospital but from an alert by the Attorney Grievance Commission

OCR not notified because it was not a data breach

An employee for Beaumont Health, an eight-hospital health system in Michigan, was caught siphoning sensitive patient information without permission then handing it over to a personal injury attorney. The medical records involved 1,182 individuals. The identity of the law firm was not identified and it is not clear how the law firm used the information. The case is under investigation and all persons whose records were compromised are being notified.

The Michigan Health & Hospital Association was notified to alert other hospitals about the incident and guard against similar intrusions. The breach was discovered on December 10, 2019, and resulted in an internal investigation. The matter was not discovered by Beaumont, but as result of an alert by the Michigan Attorney Grievance Commission—a watchdog to maintain ethical law practices in the state. How the Commission learned of the issue was not reported.

It was determined that from February 1, 2017, until October 22, 2019, the employee accessed and disclosed protected health information (PHI) without authorization. The information accessed included names, addresses, dates of birth, phone number, email addresses, reason for treatment, insurance information, and Social Security numbers. Notified individuals have been advised on how to further protect their information and monitor financial accounts for fraud. They also were asked to closely review health insurance claim information. Those having Social Security numbers exposed have been given information about enrolling in free credit monitoring, Beaumont said.  Beaumont reported that they have no experienced or reported a data hack or unauthorized patient data loss to the Office of Civil Rights that tracks and investigates breaches of patient data.

 

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 LinkedIn.

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Copyright © 202o Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: Compliance officer best practice tips

The ever increasing health care regulatory and enforcement environment increases the challenge for compliance officers. It is not enough to develop the seven standard elements of a compliance program. Compliance officers must persuade the organization to adopt those elements by changing the culture of the organization. This requires a lot of effort. It can be called preaching or selling—it amounts to the same thing. The following are suggested tips:

  1. Obtain independent evidence of compliance program improvement by periodically having independent experts evaluate its effectiveness and offer suggestions for improvements.

 

  1. Maintain ongoing metrics to benchmark progress of the compliance program effectiveness, such as using a compliance culture or knowledge survey that evidences improvements from one period to another.

 

  1. Do not compromise principle in the face of skepticism and sometimes resistance with leadership, and those who consider compliance to be a distraction to their job. Once you begin to “cave in” to their unreasonable disagreements, it creates a pathway to ineffectiveness.

 

  1. Educate management on the benefits of compliance in assisting in reducing risks that could give rise to liabilities and loss of reputation. The challenge of selling the message is ongoing.

 

  1. Sell the importance, value, and benefits of the program to the board, leadership, and the rank and file employees. Also sell the consequences not having an effective program. Gaining “buy-in” by the executive leadership and Board is the best path for the compliance officer to be effective.

 

  1. To be truly successful, compliance officers must reach and convince first line managers to carry the compliance message to their subordinates, by word and example. What they say and what attitudes they project to their staff is far more powerful than pronouncements from “on high.”

 

  1. Rank and file must see compliance as responsive to their concerns and this means actively and promptly investigating and resolving matters raised by the work force in a competent professional manner. Also, the compliance officer needs to be visible and available to hear what concerns people have; as such, it is good to walk around and talk to people about their jobs, thoughts, concerns, etc. This is all part of selling the program.

 

  1. Successful compliance officers seek cooperation and coordination of effort, not competition, with other functions that overlap with compliance, such as HR, Legal Counsel, and Internal Audit. If these functions engage in turf battles, it will negatively impact the effectiveness of the compliance program. A lot of benefit can come from developing protocols (policy documents) that establish working relationships and methods of cooperative effort.

 

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 LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 202o Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: DOJ reports 2019 False Claims Act Recoveries of over $3B

The DOJ obtained more than $3 billion in settlements and judgments from civil cases involving fraud and false claims against the government in fiscal year 2019. Recoveries since 1986, when Congress substantially strengthened the civil False Claims Act, now total more than $62 billion. Of the more than $3 billion in settlements and judgments recovered, $2.6 billion related to the health care industry.

This was the tenth consecutive year that health care fraud settlements and judgments have exceeded $2 billion. Whistleblower, or qui tam, actions comprise a significant percentage of the False Claims Act cases that are filed. Of the $3 billion in settlements and judgments reported by the government in fiscal year 2019, over $2.1 billion arose from lawsuits filed under the qui tam provisions of the False Claims Act.

During the same period, the government paid out $265 million to the individuals who exposed fraud and false claims by filing these actions. The number of lawsuits filed under the qui tam provisions of the Act has grown significantly since 1986, with 633 qui tam suits filed this past year—an average of more than 12 new cases every week. In its news release, the DOJ noted that it had increased holding individuals accountable and cited examples of actions taken against responsible executives.

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 LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2020 Strategic Management Services, LLC. Published with permission.