Justice Department Reaches Settlement with Texas Hospital Prohibiting Anticompetitive Contracts with Health Insurers

JUSTICE DEPARTMENT REACHES SETTLEMENT WITH TEXAS HOSPITAL PROHIBITING ANTICOMPETITIVE CONTRACTS WITH HEALTH INSURERS

Department Says United Regional's Contracts Unlawfully Maintain Monopoly Power

WASHINGTON — The Department of Justice announced today that it has reached a settlement with United Regional Health Care System of Wichita Falls, Texas, that prohibits it from entering into contracts that improperly inhibit commercial health insurers from contracting with United Regional's competitors. The department said that United Regional unlawfully used these contracts to maintain its monopoly for hospital services in violation of Section 2 of the Sherman Act, causing consumers to pay higher prices for health care services. This is the first case brought by the department since 1999 that challenges a monopolist with engaging in traditional anticompetitive unilateral conduct.  

The Department of Justice's Antitrust Division, along with the Texas Attorney General's office, filed a civil antitrust lawsuit in U.S. District Court for the Northern District of Texas, along with a proposed settlement that, if approved by the court, would resolve the lawsuit.

"Unfettered competition among hospitals is vital to ensuring that patients receive high-quality, low-cost health care," said Christine Varney, Assistant Attorney General in charge of the Department of Justice's Antitrust Division. "Today's settlement prevents a dominant hospital from using its market power to harm consumers by undermining its competitors' ability to compete in the marketplace."

According to the complaint, United Regional is by far the largest hospital in Wichita Falls. Its share of general acute-care inpatient hospital services is approximately 90 percent, and its share of outpatient surgical services is more than 65 percent. It is the region's only provider of certain essential services such as cardiac surgery, obstetrics and high-level trauma care. In Wichita Falls, United Regional's average per-day rate for inpatient hospital services sold to commercial health insurers is about 70 percent higher than its closest competitor for the services that are offered by both hospitals.

The department said that in order to maintain its monopoly in the provision of inpatient hospital and outpatient surgical services, United Regional systematically required most commercial health insurers to enter into contracts that effectively prohibited them from contracting with United Regional's competitors. United Regional's contracts required these insurers to pay significantly higher prices if they contracted with a nearby competing facility. Since United Regional is a must-have hospital for any insurer that wants to sell health insurance in the Wichita Falls area, and because the penalty for contracting with United Regional's rivals was so significant, almost all insurers offering health insurance in Wichita Falls entered into exclusionary contracts with United Regional. As a result, competing hospitals and facilities could not obtain contracts with most insurers and were less able to compete, helping United Regional maintain its monopoly in the relevant markets and raising health-care costs to the detriment of consumers.

The proposed settlement, which if accepted by the court would be in effect for seven years, restores lost competition by prohibiting United Regional from using agreements with commercial health insurers that improperly inhibit insurers from contracting with United Regional's competitors. In particular, United Regional is prohibited from conditioning the prices or discounts that it offers to commercial health insurers based on whether those insurers contract with other health-care providers and from inhibiting insurers from entering into agreements with United Regional's rivals. United Regional is also prohibited from taking any retaliatory actions against an insurer that enters into an agreement with a rival provider.

United Regional Health Care System is a private Texas nonprofit corporation, with its principal place of business in Wichita Falls. United Regional had net patient revenues of approximately $265 million for 2009.

The proposed settlement, along with the department's competitive impact statement, will be published in the Federal Register, as required by the Antitrust Procedures and Penalties Act. Any person may submit written comments concerning the proposed settlement within 60 days of its publication to Joshua H. Soven, Chief, Litigation I Section, Antitrust Division, U.S. Department of Justice, 450 Fifth St. N.W., Suite 4100, Washington, D.C. 20530. At the conclusion of the 60-day comment period, the court may enter the final judgment upon a finding that it serves the public interest.

Medicaid chief: Single payer may be better than ‘devil-may-be’ market

A senior Patrick administration health care official said Friday that a single payer system may work more effectively and efficiently than Massachusetts’s existing insurance market, a high-profile endorsement that raised eyebrows at a legislative hearing.
“I like the market, but the more and more I stay in it, the more and more I think that maybe a single payer would be better,” said Terry Dougherty, director of MassHealth – the state-run Medicaid plan that insures nearly 1.3 million Massachusetts residents – when lawmakers asked for his “personal view” on a single payer system.
Dougherty’s comment, made during a budget hearing at the Boston Public Library, prompted his boss, Secretary of Health and Human Services JudyAnn Bigby, to interject: “That’s his personal opinion.”

After his remarks, Dougherty told the News Service that he’s learned to appreciate “elements of single payer” during his 30 years in health care.Dougherty noted that MassHealth, by far the largest program in state government, spends just 1.5 percent of its $10-billion-a-year budget on administrative costs – compared to about 9.5 percent by the private market, according to studies by the state Division of Health Care Finance and Policy. That figure won plaudits from several lawmakers on the panel, including some who have supported implementing a statewide single payer system.
“It’s got to be better than this devil-may-be marketplace,” he said. “We don’t build big buildings. We don’t have high salaries. We don’t have a lot of marketing, which makes, to some extent, some of the things that we do easier and less costly than some things that happen in the marketplace. Overall, my point is, we have individuals who work in state government in MassHealth ... who are just as smart, just as tactile, just as creative as people who work in the private sector, but they work for a lot less money.”
A single payer system would replace the state’s patchwork of nonprofit and private insurers with a single, public insurer through which all health care dollars would flow to hospitals, doctors and other health care providers. Supporters say it would eliminate administrative waste and ensure that all residents receive adequate coverage.
But while supporters point to single payer models used by other countries and tout the idea as a cost saver, critics warn the system would result in government bureaucrats deciding what services to cover and how to pay for them, would reduce the quality of care and would disrupt relationships between doctors and patients.
Hundreds of thousands of Massachusetts residents have endorsed the approach. In fact voters in 14 House districts –including five that backed Scott Brown for U.S. Senate – voted overwhelmingly last year to support a non-binding ballot question that asked, “Shall the state representative from this district be instructed to support legislation that would establish health care as a human right regardless of age, state of health or employment status, by creating a single payer health insurance system like Medicare that is comprehensive, cost effective, and publicly provided to all residents of Massachusetts?”
A similar question passed in 10 other House districts in 2008.
Although last session 50 members of the Legislature supported a single payer model, the issue has lacked support from the upper echelons of the Legislature and the Patrick administration.
A single payer plan would scrap Massachusetts’s landmark health care system, which relies on the private insurance marketplace, and that backers have credited with helping insure about 98 percent of the population. Backers of the existing structure, while acknowledging that health care costs have continued to climb, note that the state has covered about 430,000 residents since the inception of health care reform in 2006. Individuals are required to purchase health insurance, and low-income residents without access to health care through their employers may obtain partially or fully-subsidized care through the state’s Connector Authority, an exchange that pairs consumers with private plans, or through MassHealth.
This session, only 32 members signed on to the single payer proposal, although the sponsors include several high-ranking lawmakers: Rep. Stephen Kulik, vice chair of the Ways and Means Committee; Rep. Martha Walz, assistant vice chair of the Ways and Means Committee; Reps. Ellen Story and Byron Rushing, members of Speaker Robert DeLeo’s upper leadership team; and eight House committee chairs. The bill’s lead sponsors are Rep. Jason Lewis (D-Winchester) and Sen. James Eldridge (D-Acton). Last session’s lead sponsor, Rep. Matthew Patrick (D-Falmouth) was ousted at the polls by Republican David Vieira.
Benjamin Day, executive director of Mass Care, a single payer advocacy group, noted that only six of the lawmakers in the 14 House districts whose voters endorsed single payer health care signed onto the bill. He asserted that many members of state government’s health care hierarchy support single payer health care but keep it to themselves.
“Everyone is making political considerations, tactical considerations,” he said.
Day said supporters of a single payer system are eyeing Vermont, which recently elected a Democratic governor who ran on a platform that included a single payer system.

“If Vermont passes it, that will be such an incredible boon,” he said.
Day noted that Vermont has hired key players in Massachusetts’ own landmark health reform efforts, including Jonathan Gruber, a member of the Massachusetts Connector Authority board and Anya Rader Wallack, a health care consultant who previously headed the Massachusetts Medicaid Policy Institute.
Proposals to advance a single payer system have fallen in and out of favor for decades. Before he became Senate president in 2003, Robert Travaglini was the lead sponsor of a proposal to create a task force charged with recommending ways to implement single payer health care in Massachusetts, although he later endorsed the current system, which Gov. Mitt Romney signed into law in 2006.

HHS imposes a $4.3 million civil money penalty for violations of the HIPAA Privacy Rule

HHS imposes a $4.3 million civil money penalty for violations of the HIPAA Privacy Rule

Action marks first civil money penalty issued by HHS for HIPAA Privacy Rule violations

The U.S. Department of Health and Human Services’ (HHS) Office for Civil Rights (OCR) has issued a Notice of Final Determination finding that Cignet Health of Prince George’s County, Md., (Cignet) violated the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). HHS has imposed a civil money penalty (CMP) of $4.3 million for the violations, representing the first CMP issued by the Department for a covered entity’s violations of the HIPAA Privacy Rule.

The CMP is based on the violation categories and increased penalty amounts authorized by Section 13410(d) of the Health Information Technology for Economic and Clinical Health (HITECH) Act.

“Ensuring that Americans’ health information privacy is protected is vital to our health care system and a priority of this Administration. The U.S. Department of Health and Human Services is serious about enforcing individual rights guaranteed by the HIPAA Privacy Rule,” said HHS Secretary Kathleen Sebelius.

In a Notice of Proposed Determination issued Oct. 20, 2010, OCR found that Cignet violated 41 patients’ rights by denying them access to their medical records when requested between September 2008 and October 2009. These patients individually filed complaints with OCR, initiating investigations of each complaint. The HIPAA Privacy Rule requires that a covered entity provide a patient with a copy of their medical records within 30 (and no later than 60) days of the patient’s request. The CMP for these violations is $1.3 million.

During the investigations, Cignet refused to respond to OCR’s demands to produce the records. Additionally, Cignet failed to cooperate with OCR’s investigations of the complaints and produce the records in response to OCR’s subpoena. OCR filed a petition to enforce its subpoena in United States District Court and obtained a default judgment against Cignet on March 30, 2010. On April 7, 2010, Cignet produced the medical records to OCR, but otherwise made no efforts to resolve the complaints through informal means.

OCR also found that Cignet failed to cooperate with OCR’s investigations on a continuing daily basis from March 17, 2009, to April 7, 2010, and that the failure to cooperate was due to Cignet’s willful neglect to comply with the Privacy Rule. Covered entities are required under law to cooperate with the Department’s investigations. The CMP for these violations is $3 million.

“Covered entities and business associates must uphold their responsibility to provide patients with access to their medical records, and adhere closely to all of HIPAA’s requirements,” said OCR Director Georgina Verdugo. “The U.S. Department of Health and Human Services will continue to investigate and take action against those organizations that knowingly disregard their obligations under these rules.”

Individuals who believe that a covered entity has violated their (or someone else’s) health information privacy rights or committed another violation of the HIPAA Privacy or Security Rule may file a complaint with OCR athttp://www.hhs.gov/ocr/privacy/hipaa/complaints/index.html.

Notice of Final Determination of HIPPA Violations of Cignet

States Cry Foul With Health Care Mandate

States Cry Foul With Health Care Mandate

Ever wanted to know why there was so much opposition to the health care reform?  Well here it is.

It's called fraud.  Yes, contained within health care reform is also regulation.  Here is a great little rant from the State of Florida.  Why are they ranting?  It is because they are not compliant.

Florida is so bad, the U.S. Department of Justice teamed up with the U.S. Department of Health and Human Resources to establish the Health Care Fraud Enforcement Task Force (H.E.A.T.)  The worst part of the levels of health care fraud in these states that are crying the unconstitutional foul is that the levels of Medicaid fraud, once the federal moritoria on the suspension of the rules are lifted, will make Medicare pail in comparison to the ugly beast called Medicaid fraud.
U.S. DHHS OIG and DOJ Health Care Fraud Prevention Enforcement Team
The lack of Medicaid and Medicare regulation in the states will substantially cut the federal funding to their programs.  In essence, coming into federally funded, mandated compliance to end Medicaid and Medicare fraud will kill jobs because these fraud scheme, racketeering operations will be shut down.
Department of Justice and Department of Health and Human Services response to Senator Grassley's inquiry on...

Health care law will help, not hinder, creation of jobs

Since defeat of attempts to repeal the Affordable Health Care Act, I've reflected on how little most people seem to understand about its positive effects. There are simply no words to express the importance of this act in our family right now.

A close relative and small business owner has health issues that require him to sell his company earlier than planned. When it sells, he -- like many others forced out of their jobs-- must seek health insurance as an individual. He is two years short of qualifying for Medicare; his condition will not be tolerable within that time without significant medical interventions.

Our comfort comes from knowing that, while probably pricey, insurance for our relative cannot be denied because of his pre-existing condition. Without insurance he could easily use the entire proceeds from selling his business, intended to fund his retirement.

Republicans have chosen to spend precious time trying to repeal this law, creating fears and negativity about it which are undeserved and delaying action on more urgent issues like the economy and jobs.

They continue to misrepresent the bill, branding it as a "job destroyer," (it actually creates jobs if implemented as planned), and repealing it would add billions to the nation's debt ($145 billion over 10 years). Provided the Act is implemented as planned, it will reduce our deficits -- but Republicans aim to prevent implementation.

They have stirred up a great protest to the individual mandate, but they gloss over the fact that the millions of uninsured people in today's market are key drivers of the cost increases the rest of us bear.

In a recent news magazine interview, the CEO of a major for-profit insurance company complained that the Affordable Health Care Act would force him to change his business model. Good. That model no longer works -- and we are all paying dearly so companies like his can make a profit.

Metro Detroit Medicare providers charged in fraud case

Robert Snell / The Detroit News

Detroit— Twenty medical providers from across Metro Detroit were charged today in federal court with billing Medicare for fraudulent charges.

The 20, including an Oak Park podiatrist who federal prosecutors say billed Medicare for more than $700,000 in fraudulent toenail treatments, are the latest defendants ensnared in a nationwide crackdown on Medicare fraud.

Nationwide, more than 700 law enforcement agents arrested 111 people accused of illegally billing Medicare more than $225 million. The arrests are the latest in a string of major busts in the past two years as authorities have struggled to pare the fraud that's believed to cost the government between $60 billion and $90 billion each year.

The podiatrist, Dr. Errol Sherman, is among 20 people accused of orchestrating schemes to cheat Medicare. During a four-year period ending in 2006, Sherman submitted false claims to Medicare for toenail services that were never performed, according to an indictment filed today in U.S. District Court in Detroit.

In one case, Sherman billed Medicare for 20 nail removal treatments on three toes of one patient, according to the indictment. Each treatment cost $110.

The U.S. Attorney's Office and FBI will discuss the Medicare fraud crackdown during a 2:30 p.m. news conference.

U.S. Attorney Barbara McQuade and Andrew Arena, special agent incharge of the FBI in Detroit, will talk about actions undertaken with the Medicare Fraud Strike Force, which investigates fraud, waste and abuse.

They will be joined during the news conference by Lamont Pugh III, special agent in charge of the U.S. Department of Health and Human Services, Office of Inspector General.

There are Strike Force prosecution teams in seven cities nationwide fighting fraud. The teams analyze data to identify high-billing schemes and chronic fraud by people acting as health-care providers or suppliers, according to the Health and Human Service's website.

During the 2010 fiscal year, the prosecution teams handled investigations that led to 140 indictments and criminal charges against 284 people who billed Medicare more than $590 million.

A new report released last month showed the government's health-care fraud prevention and enforcement efforts recovered more than $4 billion in fiscal year 2010.

Come back to detnews.com for updates.

Medicare Fraud Strike Force Charges 111 Individuals for more than $225 Million in False Billing and Expands Operations to Two Additional Cities

Medicare Fraud Strike Force Charges 111 Individuals for more than $225 Million in False Billing and Expands Operations to Two Additional Cities

Doctors, Nurses, Health Care Company Owners and Executives Among the Defendants Charged; Law Enforcement Agents Execute 16 Search Warrants

WASHINGTON – The Medicare Fraud Strike Force today charged 111 defendants in nine cities, including doctors, nurses, health care company owners and executives, and others, for their alleged participation in Medicare fraud schemes involving more than $225 million in false billing, announced Attorney General Eric Holder, Health and Human Services (HHS) Secretary Kathleen Sebelius, FBI Executive Assistant Director Shawn Henry, Assistant Attorney General Lanny A. Breuer of the Criminal Division and HHS Inspector General Daniel Levinson.  Also today, the Department of Justice (DOJ) and HHS announced the expansion of Medicare Fraud Strike Force operations to two additional cities – Dallas and Chicago.  Today’s operation is the largest-ever federal health care fraud takedown. 

The joint DOJ-HHS Medicare Fraud Strike Force is a multi-agency team of federal, state, and local investigators designed to combat Medicare fraud through the use of Medicare data analysis techniques and an increased focus on community policing.  More than 700 law enforcement agents from the FBI, HHS-Office of Inspector General (HHS-OIG), multiple Medicaid Fraud Control Units, and other state and local law enforcement agencies participated in today’s operation.  In addition to making arrests, agents also executed 16 search warrants across the country in connection with ongoing strike force investigations. 

“With this takedown, we have identified and shut down large-scale fraud schemes operating throughout the country.  We have safeguarded precious taxpayer dollars.  And we have helped to protect our nation’s most essential health care programs, Medicare and Medicaid,” said Attorney General Holder.  “As today’s arrest prove, we are waging an aggressive fight against health care fraud.” 

“Over the last two years our joint efforts have more than quadrupled the number of anti-fraud Strike Force teams operating in fraud hot spots around the country from two to nine -- with the latest additions Chicago and Dallas -- bringing hundreds of charges against criminals who had billed Medicare for hundreds of millions of dollars. Last year alone, our partnership recovered a record $4 billion on behalf of taxpayers.  From 2008-2010, every dollar the Federal Government spent under its Health Care Fraud and Abuse Control programs averaged a return on investment of $6.80,” said HHS Secretary Sebelius.  

The defendants charged today are accused of various health care fraud-related crimes, including conspiracy to defraud the Medicare program, criminal false claims, violations of the anti-kickback statutes, money laundering and aggravated identity theft.  The charges are based on a variety of alleged fraud schemes involving various medical treatments and services such as home health care, physical and occupational therapy, nerve conduction tests and durable medical equipment.

According to court documents, the defendants charged today participated in schemes to submit claims to Medicare for treatments that were medically unnecessary and oftentimes, never provided.  In many cases, indictments and complaints allege that patient recruiters, Medicare beneficiaries and other co-conspirators were paid cash kickbacks in return for supplying beneficiary information to providers, so that the providers could submit fraudulent billing to Medicare for services that were medically unnecessary or never provided. Collectively, the doctors, nurses, health care company owners, executives and others charged in the indictments and complaints are accused of conspiring to submit a total of more than $225 million in fraudulent billing.

“Every American bears the burden of health care fraud, and the FBI, in conjunction with our inter-agency partners, will continue to dismantle criminal networks that bilk the system,” said Shawn Henry, Executive Assistant Director of the FBI’s Criminal, Cyber, Response and Services Branch. “Our agents and analysts use task forces and undercover operations to identify individuals who treat the health care system as a vehicle to line their pockets.”

“Today, Strike Force operations have charged doctors, nurses, health care executives, and others – from Los Angeles to New York and cities in between – with engaging in Medicare fraud schemes that cheat taxpayers and patients alike,” said Assistant Attorney General Breuer.  “With this nationwide takedown and the expansion of the Strike Force to two additional cities, our message is clear: we are determined to put Medicare fraudsters out of business.”

“Today, more than 300 special agents from OIG, in partnership with federal and state agencies across the country, are making more than a hundred arrests on charges of health care fraud,” said Daniel R. Levinson, HHS Inspector General.  “These unprecedented operations send a clear message – we will not tolerate criminals lining their pockets at the expense of Medicare patients and taxpayers.”

In Miami, 32 defendants, including 2 doctors and 8 nurses, were charged for their participation in various fraud schemes involving a total of $55 million in false billings for home health care, durable medical equipment and prescription drugs.  Twenty-one defendants, including three doctors, three physical therapists and one occupational therapist, were charged in Detroit for schemes to defraud Medicare of more than $23 million.  The Detroit cases involve false claims for home health care, nerve conduction tests, psychotherapy, physical therapy and podiatry. 

In Brooklyn, N.Y., 10 individuals, including three doctors and one physical therapist, were charged with fraud schemes involving $90 million in false billings for physical therapy, proctology services and nerve conduction tests.  Ten defendants were charged in Tampa for participating in schemes involving more than $5 million related to false claims for physical therapy, durable medical equipment and pharmaceuticals.

Nine individuals were charged in Houston for schemes involving $8 million in fraudulent Medicare claims for physical therapy, durable medical equipment, home health care and chiropractor services.  In Dallas, seven defendants were indicted for conspiring to submit $2.8 million in false billing to Medicare related to durable medical equipment and home health care. 

Five defendants were charged in Los Angeles for their roles in schemes to defraud Medicare of more than $28 million.  The cases in Los Angeles involve false claims for durable medical equipment and home health care.  In Baton Rouge, La., six individuals were charged for a durable medical equipment fraud scheme involving more than $9 million in false claims. 

In Chicago, charges were filed against 11 individuals associated with businesses that have billed Medicare more than $6 million for home health, diagnostic testing and prescription drugs.

The Medicare Fraud Strike Force operations are part of the Health Care Fraud Prevention & Enforcement Action Team (HEAT), a joint initiative announced in May 2009 between the Department of Justice and HHS to focus their efforts to prevent and deter fraud and enforce current anti-fraud laws around the country.

Since their inception in March 2007, Strike Force operations in nine districts have charged more than 990 individuals who collectively have falsely billed the Medicare program for more than $2.3 billion.  In addition, the HHS Centers for Medicare and Medicaid Services, working in conjunction with the HHS-OIG, are taking steps to increase accountability and decrease the presence of fraudulent providers.

The cases announced today are being prosecuted and investigated by Strike Force teams comprised of attorneys from the Fraud Section in the Justice Department’s Criminal Division and from the U.S. Attorney’s Offices for the Southern District of Florida, the Eastern District of Michigan, the Eastern District of New York, the Middle District of Florida, the Southern District of Texas, the Central District of California, the Middle District of Louisiana; the Northern District of Illinois, and the Northern District of Texas; and agents from the FBI, HHS-OIG, and state Medicaid Fraud Control Units.

An indictment is merely a charge and defendants are presumed innocent until proven guilty.

To learn more about the Health Care Fraud Prevention and Enforcement Action Team (HEAT), go to:www.stopmedicarefraud.gov.

Twenty People Indicted in Florida for Health Care Fraud Scheme Involving Approximately $200 Million in Medicare Billing

Twenty People Indicted in Florida for Health Care Fraud Scheme Involving Approximately $200 Million in Medicare Billing

Related Action Charges Four Other Defendants with Additional Offenses

WASHINGTON – Twenty individuals, including three doctors, were charged today in the Southern District of Florida for various health care fraud, kickback and money laundering charges related to their alleged participation in a fraud scheme involving approximately $200 million in Medicare billing for purported mental health services, announced the Departments of Justice and Health and Human Services (HHS).
The 38-count indictment unsealed today in U.S. District Court in the Southern District of Florida alleges that the defendants worked with and for American Therapeutic Corporation (ATC) and Medlink Professional Management Group Inc.  According to court documents, the defendants participated in a scheme to defraud Medicare by submitting false claims for mental health services administered at ATC facilities that were medically unnecessary or not provided at all.  The indictment alleges that various defendants paid kickbacks to patient brokers and owners and operators of halfway houses and assisted living facilities (ALFs), in exchange for delivering patients to ATC facilities.  Various defendants are charged with participating in an extensive and complicated money laundering scheme related to the cash for kickback payments.  Sixteen defendants were arrested this morning in the Southern District of Florida and are expected to appear in U.S. District Court in Miami later today.   Arrests are expected to continue in the coming days.  
ATC’s and Medlink’s owners and managers, Lawrence S. Duran, Marianella Valera, Judith Negron and Margarita Acevedo, were originally indicted along with the corporate entities, ATC and Medlink, in October 2010.  A superseding 38-count indictment unsealed today in the Southern District of Florida charges them with additional offenses.

“As today’s charges reflect, defrauding the Medicare system was not an aberration at ATC, but instead part and parcel of its business operations,” said Assistant Attorney General Lanny A. Breuer of the Criminal Division.  “The alleged scheme was brazen in scope, and carried out by the company’s owners, doctors, marketers and others.  By exploiting positions of trust, these defendants masked their fraudulent operation as a legitimate mental health business.  These charges are evidence that we will pursue Medicare cheats no matter their position.”

“Community mental health centers are an essential element of the nation’s health care system and serve vulnerable populations,” said Daniel R. Levinson, HHS Inspector General.  “Today’s arrests by OIG agents and our law enforcement partners show that we will not tolerate criminals who pay kickbacks for referrals of Medicare business or who bill for services that were either medically unnecessary or never provided.”

“Community Mental Health Centers can no longer use phantom medical care as a front to bilk Medicare for unnecessary or nonexistent medical services,” said FBI Special Agent in Charge John V. Gillies of the Miami Field Office.   “The FBI and our law enforcement partners will investigate and criminally prosecute such fraud to the fullest extent of the law.”

U.S. Attorney Wifredo A. Ferrer of the Southern District of Florida stated, “Health care fraud has evolved from DME fraud, to infusion fraud, to home health care fraud, and now, as this case shows, to community mental health treatment fraud.  Worse yet, health care fraud has come to permeate every level of the health care industry, from the owners and managers of dirty clinics, to complicit doctors, program directors, therapists, marketers, and patient recruiters.  Today’s prosecution confirms that we are well-equipped and primed to fight the changing face of Medicare fraud in the Southern District of Florida, and that we will prosecute every link in the fraud chain.” 

According to court documents, ATC, headquartered in Miami, operated purported partial hospitalization programs (PHPs) in seven different locations throughout Florida, from Homestead to Orlando.  A PHP is a form of intensive treatment for mental illness.  Court documents allege that Duran and Valera orchestrated the fraud, kickback and money laundering schemes.  Negron assisted Duran and Valera in operating the schemes.  Acevedo operated the kickback scheme.        
According to court documents, doctors Mark Willner, Alan Gumer and Alberta Ayala were medical directors for ATC, and Vanja Abreu (Ph.D.), Nancy Merced-Sola and Lydia Ward (Ph.D.) served as program directors who managed ATC facilities.  Nichole Eckert was a therapist at ATC.  Court documents allege that Duran, Negron and Valera, along with the program directors and Eckert, regularly altered and instructed others to alter patient charts and notes from therapy sessions at ATC in order to make it appear that the patients being treated qualified for PHP treatments, when, in fact, they did not.  According to the indictment, Willner, Gumer and Ayala then signed the false patient charts authorizing unnecessary treatment or continued treatment for patients who were not eligible for PHP treatment, without examining the patients or the charts.  Duran and Valera also allegedly instructed employees and doctors at ATC, including Willner, Gumer and Ayala, to alter diagnoses and medication types and levels to falsely make it appear that the patients qualified for PHP treatments.
According to court documents, Valera, Willner, Gumer and Ayala manipulated the length of patients’ stays in order to maximize the number of days Medicare would pay for the PHP services.  According to a civil complaint filed in the Southern District of Florida, ATC routinely admitted patients to the PHP program who suffered from Alzheimer’s and severe dementia and therefore were not eligible for the PHP program because their mental capacity did not allow them to benefit from group therapy.
The indictment also alleges that Sandra Jimenez, Hilario Morris and Joseph Valdes were marketers for ATC and participated in the kickback operation.  These marketers, along with Duran, Valera, Negron and Acevedo, allegedly paid kickbacks to patient brokers and owners and operators of ALFs and halfway houses in exchange for delivering patients from their facilities to ATC.  The indictment alleges that defendants Mathis Moore, Nelson Fernandez, Leyanes Placeres, James Edwards, Frank Criado and Curtis Gates were patient brokers and, in exchange for kickbacks, provided patients to ATC every month from ALFs and halfway houses with which they had relationships.  The indictment alleges that the kickback payments totaled millions of dollars.
The indictments allege that the kickback scheme was supported by a money laundering scheme whereby individuals received checks in their own names or in the names of shell corporations they created, cashed the checks and returned the cash to Duran and Valera, which Duran and Valera then used to pay the kickbacks.  Defendants Adriana Mejia, Pedro Sosa, Yoisel Cancio and an unnamed coconspirator, along with Moore, Fernandez, Placeres, Edwards, Criado and Gates, allegedly participated with Duran, Valera, Negron and Acevedo in the charged money laundering conspiracy.  According to the indictment, Mejia, Sosa and Cancio received monthly, bi-weekly and weekly payments from Medlink despite the fact that they had no job functions at Medlink or ATC, other than laundering money.  The indictments also charge that Duran, Valera, Negron, Mejia, Sosa and Cancio engaged in transactions designed to conceal proceeds of unlawful activity and structured their transactions to avoid reporting requirements that require banks to report certain transactions.  According to the indictments, these defendants together laundered millions of dollars over several years.
The alleged scheme also involved a company called American Sleep Institute (ASI), which purportedly provided sleep study services.  The defendants paid additional kickbacks for some patients to also visit ASI.  Court documents allege that Willner, Gumer and Ayala furthered the health care fraud conspiracy by referring patients to ASI.
In a separate action in October 2010, a civil complaint for injunctive relief was filed in U.S. District Court in the Southern District of Florida and a preliminary injunction was obtained to freeze the assets of Duran, Valera, Negron, Acevedo, ATC and Medlink as well as ASI and D&V Development Inc., as participants in the health care fraud.  Civil court documents allege that D&V Development was owned and operated by Valera and Duran and was established in an effort to divert funds received by ATC and ASI.
An indictment is merely a charge and defendants are presumed innocent until proven guilty.
Today’s actions were announced by Assistant Attorney General Lanny A. Breuer of the Criminal Division; U.S. Attorney Wifredo A. Ferrer for the Southern District of Florida; Special Agent in Charge John V. Gillies of the FBI’s Miami Field Office; and Daniel R. Levinson, Inspector General of HHS.
The criminal cases are being prosecuted by Trial Attorneys Jennifer L. Saulino, Maria Gonzalez Calvet and Joseph S. Beemsterboer of the Criminal Division’s Fraud Section.  The related civil action is being prosecuted by Vanessa I. Reed and Carolyn B. Tapie of the Civil Division and Assistant U.S. Attorney Ted L. Radway of the Southern District of Florida. The cases are being investigated by the FBI and HHS Office of Inspector General (OIG). The cases were brought as part of the Medicare Fraud Strike Force, supervised by the Criminal Division’s Fraud Section and the U.S. Attorney’s Office for the Southern District of Florida.
Since their inception in March 2007, Strike Force operations in seven districts have obtained indictments of more than 850 individuals who collectively have falsely billed the Medicare program for approximately $2.1 billion. In addition, HHS’s Centers for Medicare and Medicaid Services, working in conjunction with the HHS-OIG, are taking steps to increase accountability and decrease the presence of fraudulent providers.
To learn more about the Health Care Fraud Prevention and Enforcement Action Team (HEAT), go to:www.stopmedicarefraud.gov .

Conyers: Constitutional Text and History Proves the Validity of Health Care’s Minimum Coverage Requirement

Contact: Nicole Triplett (202) 226-5543                                                                                                  

Wednesday, February 16, 2011

Conyers:  Constitutional Text and History Proves the Validity of Health Care’s Minimum Coverage Requirement

Minimum Coverage is Necessary to Eliminate Insurance Discrimination Against Those With Pre-Existing Conditions and Make Health Care Affordable and Available for All

(Washington)—Today, at the House Judiciary Full Committee’s Hearing on the “Constitutionality of the Individual Mandate,” Ranking Member John Conyers, Jr. (D-Mich.) and his Democratic colleagues stressed how the Affordable Healthcare Act’s foundations are constitutionally sound, invoking the Constitution’s plain language, past Supreme Court cases, and the establishment of federal programs, such as Medicare and Social Security. 

Mr. Conyers and other Judiciary Democrats emphasized the critical importance for the minimum coverage requirement to be coupled with efforts to prevent insurance companies from terminating coverage for people with pre-existing conditions.  They argued that, without the individual mandate, citizens would pay higher taxes and experience double-digit premium increases.

Below is an excerpt of Mr. Conyers’ hearing remarks:

Indeed, the position that my Republican colleagues are taking is curious.  After all, they were for the individual mandate long before they were against it. 

Senators Orrin Hatch and Charles Grassley, along with 18 of their Republican colleagues included the idea of an individual mandate in their “Health Equity and Access Reform Today Act of 1993,” their counter to President Clinton’s plan. 

Former Massachusetts Governor Mitt Romney featured an individual mandate as part of his successful health care reform law, where it helped reduce insurance premiums by 40 percent while the national average has increased 14 percent.

Given its demonstrated success, and the need to solve our national health care crisis, one would hope that my Republican colleagues would continue to embrace the idea.  But instead, they’ve gone on attack, now claiming that the individual mandate is unconstitutional. 

Were they wrong then, or are they wrong now? 

I believe that they are wrong now – Congress has the clear power under Article I, Section 8, Clause 3 of the Constitution, which gives us authority to regulate commerce between the states.  That power is augmented by Article I, Section 8, Clause 18, which grants us discretion to choose the “Necessary and Proper” means of achieving our legitimate regulatory goals.  I’d like to explain briefly why our authority here is beyond question and their counter arguments should not carry the day.

First, their core argument, that this regulates “inactivity,” requires us to accept a complete fiction.  We all participate in the health care market.  No one can credibly claim that they will never get ill or injured and, in this country, we promise emergency care for all who need it.  We should be proud of that, but we also must find a better way to pay for it.  The cost of uncompensated care was $43 billion in 2008 alone, and those costs are shifted to other Americans who pay higher taxes and increased fees for medical care and insurance premiums. The individual mandate recognizes the reality that we are all “active” in the health care market and regulates how and when we pay for our health care.  Doing so is well within Congress’s power.

Second, while some of my colleagues may score political points by making this “inactivity” argument, it is – as President Ronald Reagan’s Solicitor General Charles Fried explained to our Senate colleagues – “in any event irrelevant” as a matter of law. 

Solicitor General Fried is not a partisan supporter of the Affordable Care Act, but he is a staunch defender of our Constitution. In his view, the individual mandate is fully constitutional because Congress unquestionably has the power to regulate the interstate health and insurance markets and discretion to choose the “Necessary and Proper” means of doing so.  He testified on this before our Senate colleagues and I would like to seek unanimous consent to enter his statement into the record today.  

Finally, we have been hearing that this is all about individual liberty, the right to be let alone.  But is it really?  For example, states can, and do, require citizens to purchase car insurance.  And, in Massachusetts, legislation signed by former Governor Romney obligates that state’s residents to purchase health insurance.  Many other laws impose affirmative obligations on our citizenry:  we must pay taxes, send our children to schools and vaccinate them, contribute to Medicare and Social Security, to name just a few. Surely some citizens would like to avoid these requirements as well.  But, aside from religious objectors, who also are excused here, they have no constitutionally recognized right to do so.  The liberty interests at stake do not change simply because it is the federal, rather than the state, government that is imposing the requirement.  While we can debate whether the Congress has the power to impose this requirement – something I believe we clearly do – we should not scare Americans into believing that how we resolve that question says anything about their individual liberty.

I look forward to hearing from our witnesses today, and hope that they can shed additional light on the points that I have made.

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Single Payer Health Care Fraud Prevention Powerpoint and Speaker Notes

Single Payer Health Care Fraud Prevention Powerpoint and Speaker Notes

Single Payer Health Care Fraud Prevention Powerpoint.  This is the next phase in implementation of the National Health Care Act introduced by Congressman John Conyers.
A Roadmap for New Physicians: Avoiding Medicare and Medicaid Fraud and Abuse Powerpoint
A Roadmap for New Physicians: Avoiding Medicare and Medicaid Fraud and Abuse: Speaker Notes

Feds Sentence Novartis For Drugging Kids

Trileptal is a common drug that was readily prescribed to foster children and other low income children for false claims and false diagnoses.  Novartis paid off doctors to ghostwrite reports to drug kids.

Children in foster care are still being prescribed Trileptal as mood stabilizers and not was it was approved for.  Someone needs to ask Maura Corrigan about this.

Novartis Pharmaceuticals Sentenced For Off-Label Drug Marketing
I cringe when I see the growing list of pharmaceutical corporations that not only drugged kids for cash, but drugged the entire industry of child welfare to believe that it was a good thing for kids.

When you look at the national statistics, you will see a category labeled as " physical neglect".  Physical neglect has 12 codes assigned to break down the different categories for purposes of research studies.

There are two specific codes which address issues of medical neglect:

Refusal to allow or provide needed care for diagnosed condition or impairment.

Unwarranted delay or failure to seek needed care

TRANSLATION: When a parent refuses psychotropic medication to the child, this constitutes medical neglect, a reportable condition to increase the national statistics of child abuse and neglect, and grounds for removal.

This is a classic Title IV-E funding training technique (usually billing at the improper higher rate of 75%) where a Child Welfare Worker will use the tactic of performing an Axis III diagnosis, without medical license, to support the placement of the child in foster care and to automatically classify the child as special needs, accessing Targeted Case Management funding benefits called kiddy kickbacks.

Novartis resolves its own kiddy kickback liabilities, generated from Social Securitydollars while the States child welfare systems continue its pattern of practice of promoting the drugging of children.

Trileptal is a commonly prescribed as a psychotropic drug for foster children.

Wolverine Human Services of Michigan uses this drug liberally with foster children.

Here are two physicians who participated in the illegal and wrongful marketing of Trileptal.

Demitri and Janice Papolos

Trileptal Illegal Marketing Material