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Fraud In Health Care, The New Norm May 9, 2012

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A medicare fraud strike force team has uncovered medicare fraud in the amount of $450 million in false medicare fillings.  This has affected 52 health care providers in the following cities: Miami, Houston, Baton Rouge, Detroit, Los Angeles, Tampa and Chicago.

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Welfare Fraud Prevention May 3, 2012

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Deputy Chief Todd Delain of Brown County has investigators looking into tips of welfare fraud prevention for Brown County’s Food Share/Medicare program.  The issue here is to make sure that individuals who are not medicare recipients, do not have access to the Food Share program through the programs debit cards. In 2011, more than 100 cases of potential medicare fraud were investigated.

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Big Bust With Medicare Fraud May 3, 2012

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One hundred and seven doctors where charged with medicare fraud in one of the justice department’s largest medicare fraud cases.  The amount of medicare fraud commited, reached up to $225.6 million for unnecesssary health care charges.

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Highmark, Ultra reports and Medicare Audits – handle them by yourself at your own risk (or, why smart Doctors lawyer up) June 1, 2011

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Medicare is a pain to deal with.  That’s why you love your billing manager so much right?  Well, if you get a letter from Highmark indicating that an ULTRA report shows an  aberrancy in your practice with regard to certain billing codes, I suggest you call a good Medicare fraud lawyer right away.  The problem with the initial letter from Highmark is that is not really that threatening.  It just lets you know that there is an issue.  For the most part, you don’t really have to even do anything; there is nothing to even fill out.  You could just file it away and ignore it right?

That could be a huge mistake.  Sometimes after the letter with the ULTRA report, you will be targeted for an audit.  The audit starts with a request for medical records for approximately 25 to 35 patients or services.  These medical records will be reviewed internally which will generate an analysis that either supports your utilization or determines that the services were not covered for a variety of reasons, i.e., medical necessity, failure to abide by policies such as mandatory surgical second opinions or some other cause such as fraud. You will then be permitted to submit additional information which can then be submitted to an outside reviewer.  Clearly, the big issue here is whether it appears that you are billing for services that did not occur or that you are intentionally over billing.

When records are requested, you should an attorney helping you through the process.  The records you initially supply will be used to determine whether you will be subject to a refund request and further review.  This could be your last opportunity to present all of the information necessary to support your actions in an attempt to avoid a costly audit and investigation.  Your attorney should help you decide what to say and how much information to provide although it generally helps to provide as much information as possible but the records have to be organized and easy to read/understand.  Your attorney may also have the records reviewed by an outside reviewer to bolster your position that your actions/practices are correct.

Please keep in mind that Medicare and Highmark can/will use the records that you have provided as a sample to generate refund requests covering the three year period prior to the services. For example, if 20 services are reviewed and it is determined that 10 of those services were unnecessary, then you may be subject to a refund request for 33% of all of the money that was paid for you for those services for the prior three years.  That could be a very large sum of money.

Of course, you can and should speak to your attorney about disputing the ULTRA report and not waiting for the audit.  First, review the ULTRA report to make sure that you are correctly characterized with regard to specialty as your practices are compared to your peer group (i.e. other physicians in your specialty).  I’ve had cases where Highmark’s ULTRA report was not correct because my client had a very unique practice and thus, the peer group was not correct.  You then need to review your billing practices with regard to those procedure codes in order to defend your practices or to revise that practice.   In other words, assume you had to testify tomorrow.  Would you be able to explain everything you did or your billing manager does?  Are all of your records in order?  Could you prove everything as if the burden of proof was on you?  You also want to see how far above the 95% percentile you are.  The closer you are to being off the charts, the greater the danger for not only an audit, but also a fraud investigation or prosecution.

Remember, even if you are found not guilty, your reputation is too important to risk.  Don’t handle this yourself.  Call a good attorney right away.

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Doctor Convicted in Medicare Fraud Scheme March 13, 2010

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Farmington Hills, Mich., physician Jose Castro-Ramirez was convicted by a Detroit federal jury on all 13 charged counts in connection with his role in an $18.3 million Medicare fraud scheme.

After a three-week trial, the jury convicted Castro-Ramirez of one count of conspiracy to commit health care fraud, 11 substantive counts of health care fraud, and one count of conspiracy to launder the proceeds of the fraudulent scheme.

Evidence at trial established that beginning in late 2003, the defendant, a physician licensed in the state of Michigan, entered into an agreement with co-conspirator Suresh Chand to defraud the Medicare program. Chand owned and controlled several companies operating in Warren, Mich., including Continental Rehab Services Inc. (CRS) and Pacific Management Services Inc. (PM), which purported to provide physical and occupational therapy services to Medicare beneficiaries. In reality, as the evidence showed, Chand and his associates at CRS and PM created fictitious therapy files, appearing to document physical and occupational therapy services provided to Medicare beneficiaries, when in fact no such services had taken place. The fictitious services reflected in the files were billed to Medicare through sham Medicare providers controlled by Chand and his co-conspirators.

Evidence introduced at trial established that in order to create the fictitious files, Chand and his co-conspirators paid cash kickbacks and other inducements to Medicare beneficiaries, in exchange for the beneficiaries’ Medicare numbers and signatures on documents falsely indicating that they had received therapy services. Evidence also showed that Chand paid licensed physical and occupational therapists to sign fictitious “progress notes” and other documents that appeared to reflect that physical and occupational therapy services had been provided to the beneficiaries, when in fact they had not. Castro-Ramirez signed therapy prescriptions and other documents in the files falsely indicating that he had evaluated the Medicare beneficiaries and certified the need for physical and occupational therapy services. In fact, the evidence at trial established that Castro-Ramirez had not overseen any treatment provided to the patients and was fully aware that his signatures were part of a fraudulent scheme. According to evidence presented at trial, in many instances Castro-Ramirez had never seen the beneficiaries.

One of the inducements that Chand and his co-conspirators used to recruit Medicare beneficiaries into the scheme was the provision of prescriptions for controlled substances and other drugs, including Vicodin and Xanax. Evidence presented at trial showed that Chand provided Castro-Ramirez with lists of the controlled substances or drugs the beneficiaries preferred, and that Castro-Ramirez wrote prescriptions for the substances without ever seeing the patients. The evidence established that between January 2003 and March 2007, Castro-Ramirez wrote thousands of prescriptions for a variety of drugs for patients that he had never seen. The evidence also showed that Castro-Ramirez was fully aware that the purpose of the prescriptions was to induce beneficiaries into the scheme.

Evidence introduced at trial demonstrated that Castro-Ramirez profited from his participation in the scheme in several ways. Castro-Ramirez’s largest source of fraudulent proceeds came from his own billings to Medicare for “home visits” that he purportedly made to Medicare beneficiaries whom Chand recruited into the scheme. In fact, Castro-Ramirez never conducted “home visits” with the vast majority of these patients, and never discussed or ordered therapy services for the few he did see. The evidence showed that Chand and other co-conspirators also distributed proceeds of the fraud directly to Castro-Ramirez on occasion, and did so through transactions designed to disguise the nature, source, ownership, control and location of the tainted funds. The evidence showed that Castro-Ramirez knew that the cash and checks he received from Chand were structured so as to conceal the fact that they were proceeds of Medicare fraud.

Between approximately January 2003 and June 2007, Chand and his co-conspirators submitted claims to the Medicare program totaling $18,379,300 for physical and occupational therapy services that were supposedly ordered and supervised by Castro-Ramirez, but were in fact never rendered. Medicare paid $8,562,688 on those claims. In addition, Castro-Ramirez submitted approximately $1.4 million in claims to the Medicare program for “home visits” supposedly provided to beneficiaries recruited into the scheme by Chand and his co-conspirators. Medicare paid approximately $929,000 on those claims.

Chand pleaded guilty on Sept. 28, 2009, before U.S. District Judge Sean F. Cox to one count of conspiracy to commit health care fraud and one count of conspiracy to launder money.