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Payers & Providers Midwest Edition – Issue of October 2, 2012

Payers & Providers Midwest Edition – Issue of October 2, 2012

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Published by PayersandProviders
Payers & Providers is the Midwest's premier healthcare business journal.
Payers & Providers is the Midwest's premier healthcare business journal.

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Published by: PayersandProviders on Oct 02, 2012
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2 October 2012

Midwest Edition
October 3-5
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Fraudsters Under Pressure In Midwest
Home Healthcare Latest Target in Medicare Busts
Recent federal charges led against nine home healthcare business owners and employees in the Chicago area have added to growing list of individuals being prosecuted for Medicare fraud in the Midwest. Registered nurse Ana Nerissa Tolento and Frederick Magsino, co-owners of Rosner Home Healthcare Inc. in Skokie, Ill., and former employee Edgardo Hernal, were charged last week with conspiracy for paying kickbacks to six individuals for referrals of Medicare patients to the business. Their co-defendants are physicians Emmanuel Nwaokocha, M.D. and Masood Syed, M.D.; Jenette George, from the Ttenej Senior Referral Agency which provided senior citizens with referrals to home health agencies; Jennifer Holman, an ofce manager; and marketing professionals Titis Jackson and Carla Phillips-Williams. Eight of the nine defendants were charged with two or more counts of violating the anti-kickback statute. According to the indictment released in U.S. District Court, the defendants conspired to pay bribes to doctors, marketers, nurses, ofce staff and others to refer Medicare patients in need of home health services to Rosner. The kickbacks ranged from $300 to $600 for every new patient who completed ve home health visits and for repeat admission of a previous patient into the program. Between January 2008 and January 2012, Rosner was paid approximately $13 million for home health claims submitted to Medicare, according to the complaint. The complaint also claimed the co-defendants received total payments ranging from $1,500 to $24,000 for their referrals. The violations carry a maximum penalty of ve years in prison and a $250,000 ne per count. Those indictments come on the heels of federal charges led against Goodwill Home Healthcare Inc. and ve of its operators and associates in August, according to the U.S. Department of Justice. In Detroit, physician Hicham Elhorr, M.D., was charged late last month with allegedly masterminding a billing scheme that defrauded Medicare of as much as $40 million. Elhorr was also accused of paying kickbacks in order to enroll Medicare enrollees into home healthcare programs. The cases are being pursued by the Medicare Fraud Strike Task Force, a partnership of the Justice Department and the Department of Health and Human Services. The task force is a portion of the Health Care Fraud Prevention & Enforcement Action Team. Since its creation in 2007, the strike force has

November 15-16

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December 4-5

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Continued on Next Page

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Fraud (Continued from Page One)
charged more than 1,330 defendants who have been accused of falsely billing Medicare of more than $4 billion. “Money cannot be permitted to be the basis of a medical referral over medical necessity or quality of service,” said Lamont Pugh, a HHS special agent who is in charge of the Chicago region for the agency. The strike force is located in nine cities and expanded to Chicago in February 2011 – part of a crackdown on healthcare fraud that has been pursued by the Obama Administration since early 2010. In the Midwest in the past year, 60 defendants have been charged with Medicare fraud. The strike force has not only ratcheted up prosecutions, but has courted the media, conducting “fraud summits” in Medicare fraud hotspots such as Miami and Los Angeles. Felicia Manno Alesia, an Assistant U.S. Attorney based in Chicago, said her ofce is still prosecuting the same kind of cases as before the task force’s creation but its support has made its efforts more “robust and focused.” The task force provides both money and resources for the organization. Manno Alesia said the additional funds help pay for prosecutors and investigators. “We are constantly in need of more agents and we have to wait to get to cases because we just don’t have prosecuting attorneys (available),” she said. Her ofce is also able to use national resources such as data analytics, which is a major driver of investigations. Justice Department analysts are able to compile data to see which claimants are billing highest in proportion to others, who has the highest number of Medicare patient enrollees; how many patients are being treated by the same doctor, and many other variables that can catch the eye of law enforcement.

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In Brief
Minnesota Receives $42.5 Million Grant For Health Insurance Exchange
The state of Minnesota has received a third grant from the federal government toward the construction and launch of its health insurance exchange. The $42.5 million grant is the largest received by the state to date for exchange construction and operation. Minnesota has received a total of $70.3 million. Open enrollment for exchanges in most states will begin in less than a year, with coverage going into effect on Jan. 1, 2014. “This grant is urgently needed to perform the critical development work to keep the project on track,” said exchange director April Todd-Malmlov in a statement. In addition to Minnesota, exchange grants were also announced last week that were awarded to Arkansas, Kentucky, Colorado, Massachusetts and the District of Columbia. Several states, including Texas, Florida and South Dakota, had said they would not participate in building their own exchanges. The federal government will construct and operate exchanges when state governments opt out.

Manno Alesia said the feds have always prosecuted more traditional fraud cases involving durable medical equipment, and physicians who are billing and diagnosing inappropriately. But one of the newer areas that has become especially problematic in the Midwest is home healthcare. The state of Illinois, and Cook County in particular, has an inordinate amount of home health providers in relation to its population, ofcials said. Cook County also has a very high rate of billing for this kind of service. Since June, federal prosecutors in Chicago have had three cases in a row that focused on home health providers – with doctors referring patients or kickback allegations. Home health is meant for patients who have been in the hospital and need services after their treatment. But recruiters for crooked providers are using people who go door-to-door to bring patients into home health programs. “You shouldn’t be receiving home health services because someone knocks on your door and asks you if you need it,” Manno Alesia said. “It should be something a doctor should refer you to.” Psychiatric services are another area with problems – particularly providers billing for services that aren’t provided or when an unlicensed professional bills for treatment. Medicare is an attractive target for fraud because it has huge enrollee numbers and pays relatively well. The program also has traditionally engaged in perspective auditing – asking questions after payment has been made. That has changed with the creation of the task force, meaning claims are scrutinized as they are submitted, Manno Alesia said. The program has been successful enough that the special task force in Chicago recently received funding for two more years, according to Manno Alesia. _TAMMY WORTH

Michigan Blues Grant Will Fight Childhood Obesity
Blue Cross Blue Shield of Michigan will award $600,000 to

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Henry Ford Opens Cancer Center
Personal Services Intended to Draw More Patients
Although Henry Ford Hospital in Detroit is already Michigan’s leading provider of oncology services, it did not deter the 802-bed hospital from opening a comprehensive cancer center last month. The Center for Cancer Surgery includes same-day appointments, concierges and care coordinators for patients; on-campus housing for their families; and an around-the-clock call-in line. “We designed the center to focus entirely on the patient – from scheduling a multidisciplinary tumor board evaluation and providing a highly reputable source for patient second opinions,” said Steven N. Kalkanis, M.D., a Henry Ford neurosurgeon who was appointed the center's medical director. Kalkanis was recruited by Henry Ford in 2004 from Massachusetts General Hospital and a faculty position at the Harvard University School of Medicine. In addition to its personal services, the center also includes Michigan’s rst intraoperative MRI scanner. The device will allow its real-time use during delicate procedures such as the removal of brain tumors. Altogether, Henry Ford’s Detroit campus treats about 14,000 cancer patients per year. Hospital ofcials did not release any estimates for whether the new center would grow its oncology patient load, but ofcials said it expected patients from around the world would seek treatment on-site.

In Brief
20 elementary schools across the Wolverine State in order to combat childhood obesity. About 10,000 students in the schools will receive equipment, professional training and materials to better educate children about the perils of obesity. The programs at the schools will be implemented by the Wayne State University Center for School Health and the Michigan Fitness Foundation. “We are very excited to join this partnership and the take the lead in promoting the health and well-being of so many of our children, many of whom reside in Michigan's most underserved communities," said WSU Center for School Health Director Nate McCaughtry, M.D. A new report by the Trust for America’s Health estimated that nearly six in 10 Michiganders could be obese by 2030, driving up the rate of chronic conditions such as diabetes and heart disease, and causing healthcare costs to soar.

HIEs In Indiana, Michigan Link Up
Initial Intent is to Share Patient Vaccination Records
Health information exchanges in Indiana and Michigan have established interoperability across their state lines, allowing the sharing of information regarding patients who are treated far from their homes. The connection between the Michigan Health Information Network and the Michiana Health Information Network in Indiana will be used initially to share immunization data between the states, but could be used for more serious healthcare applications in the future. The information sharing will be facilitated through the Direct Project, an initiative created by the federal National Coordinator of Health Information Technology. It provides a secure e-mail system that allows for information sharing while preserving patient condentiality. Both Indiana and Michigan exchange ofcials decided to expand information sharing after a successful pilot project. “With so many of our residents crossing state lines for care in our neighbor states of Indiana, Illinois, Ohio, and Wisconsin, we have to remember that healthcare knows no boundaries and adapt accordingly for the health and welfare of our citizens,” said MIHN Associate Director Jeff Livesay. Livesay added that his exchange would soon reach out to Sun Belt states such as Florida and Arizona to share records of patients who often venture South for the winter.

WellPoint Will Sell $1.35 Billion In Corporate Debt
Indianapolis-based health insurance giant WellPoint, Inc. is issuing $1.35 billion in long-term institutional debt. The senior convertible debentures are payable in 2042, with interest and other terms subject to negotiation between WellPoint and potential buyers. The debentures will be available to institutional investors only. WellPoint officials said it would use the capital raised from the offering to buy back approximately $600 million of its stock, to retire other debt, and for other general corporate purposes.


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So, Canada – What Are You Offering?
Our Take On Its Healthcare Is Not Always Applicable
Obamacare can be described as a lot of than six days. different things, but it surely is not socialized Wait times for elective and non-emergency medicine. No self-respecting socialist would surgery were even more disparate: Thirty-three favor having the government write checks for percent of Canadians reported a wait time of 16 million people to buy coverage from private more than four months, but only 8% of (and often for-prot) private health insurance Americans had to wait that long. In another companies. Plus, the Affordable Care Act study, 27% of Canadians said that waiting times maintains the employer-based coverage system were their biggest complaint about their health from which the vast majority of Americans will system, versus only 3% of Americans. continue to get coverage. But wait a minute, does Canada’s longer I originally wrote this opinion from a waits for some specialty care result in poorer country that has the real thing: Canada. The clinical outcomes and poorer health? No, says American College of Physician’s Board of the center, because “on most measures of Governors met last month in beautiful patient-reported physician quality, Canada Vancouver, British Columbia. comes out slightly ahead of us. . . Fewer So what can we learn from Canada? I reported physician errors, lab errors, medication wouldn’t say that my brief visit here errors and duplicate tests north of the makes me an expert on Canada’s border, and Canadians report more By socialized healthcare system. But so far, satisfaction with their doctors. General Bob Doherty health is also better up north, I haven’t seen masses of extremely ill patients desperately queuing up in long according to the World Health lines to get healthcare from beleaguered Organization: life expectancy and healthy life doctors and hospitals – even though this is the expectancy are both higher in Canada; infant image conjured up by critics of Canadian mortality is lower, and maternal mortality is healthcare. signicantly lower. There are fewer deaths from But casual observations, of course, non-communicable diseases, cardiovascular aren’t really a fair way to evaluate Canada’s diseases and injuries in Canada. socialized healthcare system. It is certainly My takeaway is that Canada’s system, like possible that lurking behind a seemingly ours has strengths and weaknesses. Canada isn’t healthy and contented Canadian population is the healthcare Nirvana that some liberals a system that is denying needed care and believe it to be, but neither is it the healthcare causing unnecessary suffering and death. hell that conservatives describe. It is a system So instead of casual observation and that covers everyone, with lower administrative conjecture, what does the evidence tell us? costs and at a much lower overall cost than the The highly respected, non-partisan United States, with longer waits for some care Annenberg Public Policy Center runs a than U.S. residents are accustomed to, but with website, www.factcheck.org, that factually comparable (and in some cases better) evaluates the evidence behind competing outcomes. Obamacare would take us a step public policy claims. It’s short answer to the closer to Canada, in the sense of extending question “Is healthcare better in Canada?” is coverage to 92% of U.S. residents, but through a that “Wait times are longer in Canada, but decidedly non-socialistic model of subsidized health and doctor quality don’t seem to suffer.” private and public health coverage – and at a More specically, the Annenberg Center much higher cost. reports that “A study by the Commonwealth Fund, a nonpartisan research foundation that promotes improved healthcare access and Bob Doherty is the senior vice president for quality, showed that 57% of adults in Canada governmental affairs and public policy at the who needed a specialist said they waited more American College of Physicians. A version of than four weeks for an appointment, versus this opinion article was originally published in only 23% who said so in the United States. For The ACP Advocate Blog. emergency physician visits, 23% of Canadians and 30% of Americans said they could get in Op-ed submissions of up to 600 words are to see the doctor the same day, but 23% of welcomed. Please e-mail proposals to Americans and 36% of Canadians waited more editor@payersandproviders.com

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