OIG Enforcement Actions and Physician Compliance American Podiatric Medical Association Julie Taitsman, J.D., M.D. Chief Medical Officer Office of the Inspector General Geeta Taylor, J.D., M.P.H. Office of Counsel to the Inspector General Office of the Inspector General November 8, 2013
OIG s Mission To protect the integrity of HHS programs and the health and welfare of program beneficiaries
Health Care Fraud is a Serious Problem $ 6.9 Billion in recoveries in FY 2012 $55 Million recovered from civil and criminal actions against physicians 778 criminal actions 367 civil actions 3,131 exclusions
Fighting Fraud Who is Investigating? OIG, DOJ, FBI, States What are the enforcement tools? Criminal statutes, civil authorities, administrative sanctions Where to cases come from? whistleblowers, hotline complaints, audits, contractors, states, data analysis
Examples of Enforcement Samir Zaky, DPM Convicted of 14 counts of Health Care Fraud and 14 counts of False Statement Relating to Health Care Matter Defrauded Medicare by billing for partial or complete avulsion of a single nail plate, when only routine foot care was provided.
Upcoding Errol Sherman, DPM Indicted of 5 counts of health care fraud Submitted fraudulent claims for nail plate avulsion Interviews with beneficiaries found that either services were not performed, or routine foot care Data Analysis
Unbundling Michael Allen, DPM and Lexington Foot and Ankle Center Allegedly unbundled billings for initial visit to prescribe orthotic devices from follow-up visits to fit the device Allegedly unbundled billings for removal of Kwire appliances implanted during surgery from the initial surgery code Settlement amount: $419,000
Unqualified Individuals Dr. Michael Karson, DPM Convicted of Health Care Fraud, sentenced to 16 months imprisonment and restitution of $118,000 to Medicare Billed for services rendered by his office manager Removing ingrown nails, wound debridement, nerve block injections, physical therapy
Medically Unnecessary Services Dr. David Ferraro Allegedly submitted claims for medically unnecessary custom molded shoe inserts Settlement amount: $93,000
Services Not Rendered John Swenson, DPM Offered sympathetic therapy as a treatment for chronic, intractable pain Services primarily provided by unqualified and unlicensed employees Billed using podiatry clinic s practice number and using physical therapy CPT codes Settlement: $300,000 and 5 year Integrity Agreement
Exclusion from Medicare and Medicaid 3,131 individuals and entities 237 physicians 5000 physicians with ongoing exclusions
Basis for Exclusion Mandatory Permissive Conviction Minimum 5 year term 16 different basis Term of exclusion varies based on grounds (b)(4)
Effect of Exclusion: Payment Prohibition All Federal health care funds Goes beyond direct patient care. Preparation of surgical trays in a hospital Person inputting prescription information for pharmacy billing Administrative and management services
William Holley Convicted of Theft from a Health Care Benefit Program Submitted claims for wedge excisions, when only routine foot care was provided Basis: conviction related to the delivery of an item or service under Medicare or Medicaid 5 year exclusion upheld
Edward Horvath Convicted of Felony Medicaid Fraud and Felony theft from Medicare License suspended by state board Sentenced to 14 months home detention, 5 years probation, restitution $350,000 Basis: conviction related to the delivery of an item or service under Medicare or Medicaid 13 year exclusion upheld
John Cavalli From 2003-2005 billed Medicare for services provided by unqualified personnel, billed for services not rendered, upcoding Pleaded guilty Felony Conspiracy to Commit Health Care Fraud Sentenced to 1 year incarceration, $92,000 restitution, surrendered license to practice Basis: 10 year exclusion upheld
Larry Bernhard, DPM Billing while excluded Excluded in 2007 for billing Medicare Part B for services not rendered Pleaded guilty to health care fraud and aggravated identity theft for fraudulently billing Medicare Part C for patients he had never seen Sentenced: 54 months prison, restitution of $1.2 million
Mandatory Compliance Programs Affordable Care Act: Mandatory Compliance Programs Are Coming Where do things stand now? HHS has not yet finalized the requirements HHS will advance specific proposals at some point in the future But you don t need to wait. Good idea to establish a robust compliance program right away
Seven Fundamental Elements 1. Written policies and procedures 2.Compliance professionals 3. Effective training 4.Effective communication 5.Internal monitoring 6.Enforcement of standards 7.Prompt response
Education and Training
Fraud and Abuse Laws False Claims Act Anti-Kickback Statute Physician Self- Referral Statute Exclusion Statute Civil Monetary Penalties Law
Education and Training Interactions with Industry
Billing Upcoding Unbundling Duplicate Billing Billing for Services Not Rendered Billing for Medically Unnecessary Services
Accurate medical records are critical
Compliance Program Tips #1 Make compliance plans a priority now #2 Know your fraud and abuse risk areas
Make an Audit Plan Proactively audit: Coding Contracts Care
Policies and Procedures Policies and procedures should be up-to-date and user-friendly
Enforce Policies and Procedures Act promptly when issues arise Take and document corrective action
Thank You www.oig.hhs.gov Julie Taitsman julie.taitsman@oig.hhs.gov Geeta Taylor geeta.taylor@oig.hhs.gov