2011 HEAT Provider Compliance Training - Health Care Fraud Enforcement Panel with Special Agent

Uploaded by OIGatHHS on 03.06.2011

>> Nick: Good afternoon, all, as Spencer said my name is Nick DeGiulio, I'm the Special Agent
in Charge for the United States Department of Health and Human Services,
Office of Inspector General, Office of Investigations in Region 3.
We cover Pennsylvania, Delaware, Maryland, Virginia,
West Virginia, and the District of Columbia.
So on behalf of the Office of Investigations and I've been here for 20 years
so let me just say this, I've been doing this job for 20 years I've seen many,
many fraud schemes I've seen people get put in jail and pay money back because of violations
and the False Claims Act and I've seen the Compliance Programs grow exponentially
since I've started back in the 80's.
There really wasn't much of a healthcare compliance industry and I watched it grow
and really go from 0 to 60 and now it looks like from 60 to 120 as we gear
up for more people enrolling in the programs and we've definitely seen the impact.
I've seen it in my region and we've seen it nationally the impact
of stronger compliance programs throughout the country
and we'll give you some examples of that.
So we thank you for that and thank you for making your compliance programs better,
stronger, more proactive, and more responsive and cooperative with law enforcement.
While I work with a dedicated group of criminal investigators whose goal is the swift
prosecution of crooked healthcare providers as everyone says and we do appreciate
that there are honest healthcare providers out there working
to deliver necessary high quality services in an economical fashion.
We just don't see too many of those everyday we deal with the bad ones
and we see them all the time and we're making an impact and putting those people
in jail and treating them the right way.
Our goal at the Office of Investigations are to support criminal charges against providers
who submit false claims or lies to the Medicare program, Medicaid programs for money.
We're really looking for the lies the blatant lies for the money.
We support Civil False Claim's Act cases.
You saw the guy with the head in the sand just trying to avoid the rules, right,
so when people just disregard our rules submit false claims
and collect money we use the Civil False Claim's Act as a remedy there.
And then at the end of the day we will support administrator exclusion
against providers deserving providers and entities who violate our rules
and who are deserving of the exclusion action.
We vent all complaints that come into the office whether they come in by people
or whether they come in by data, you know, we take our job very seriously we don't want to go
after the false positives we want to make sure that when it comes to us from data we look
at the data we, you know, we look at all angles of the data we look
for reasons why it could be a legitimate aberration or statistical aberration;
there are certain procedures that stick out like sore thumbs but there's a reason for it
and it's perfectly legitimate so just because you hit every bell and whistle in the universe
under a certain procedure code doesn't mean we're going to come
in with our law enforcement gear and take everybody out, so -- .
We are responsible with the way we handle data and investigations.
Use common sense and you've heard most of this this morning and I'll repeat much
of what you heard but use common sense to avoid prosecution.
Be proactive in your compliance, understand all the rules relating
to your businesses making sure that everyone in the organization,
everyone in the organization is fully trained and stays within the law,
keep good accurate records of the training
and make sure you know everybody who's gotten their training sessions and who's been there
and keep good records of attendance, make sure your medical records are real and not loaded
with fabrications intended solely to gain insurance coverage for a product or a service
or to increase a reimbursement rate, keep the medical records real.
Money has the power to distort medical judgment and honest business services
so don't disregard any kick-back statutes in related laws
when you formulate your compliance programs.
Look at the contracts.
Unfortunately at the Office of Investigations we're going to continue to see cleverly
where the contracts that are really just disguises for kick-back violations.
We see this everyday and we're going to continue to uncover those fraudulent contracts.
Find problems before we do.
We're not proud, you know, we'll take them when you bring them to us.
Fully investigate, fix, and disclose them, be honest in the face
of an audit don't fix the charts, don't have chart fixing parties.
If your charts are deficient or they don't exist tell us our charts are deficient
and they don't exist, right, and we'll take it from there.
Don't withhold information or conceal facts and remember that there are criminal statutes
that address the obstruction of a federal audit whether it's an HHS audit, the CMS audit
or any other audit that's out there by the government.
If you become subject to an OIG investigation fully comply
with all subpoenas don't destroy anything, don't hide anything, don't lie to investigators.
If you're subpoenaed to appear before the Grand Jury obviously tell the truth.
Remember the criminal statutes associated with obstruction of justice,
obstruction of criminal investigators,
and lying to federal investigators and federal authorities.
Nobody's perfect if you find yourself involved in a scheme cooperate with us;
there are many examples of people who have cooperated
with the government even though they were involved in a scheme to defraud
that they got more better deals and more leniency at the end.
If we knock on your door with a search warrant,
arrest warrant we're not just doing it for fun don't resist, right?
We have to conduct a fair investigation we've already done that we've gained approval
from a prosecutor and approval from a judge and we're obligated to proceed, so use common sense
and be honest in the face of adversity it only gets worse when you lie and conceal.
[ Background noise ]
>> Nick: I'm going to give you a quick example of not to be negative
but I will give a quick example of a poor compliance habits
from a provider that we saw in our region.
CMS and the OI identified a top provider for billing the highest level E&M code 99215 60%
of the time, right, so we looked at it we saw there were prior audits, 2 or 3 prior audits.
Each time they said these are not the most complex level office visits these should be 1,
2's or 1, 1's at the most based on your medical record, on your medical record.
So the provider instead of, what we believe, falling into compliance instead of 60% they went
up to 90% 99215's but their charts look great so every time the auditors went in to look
at this stuff this practice learned how to make the charts look legitimate
so they kind of turned it against us.
And also this provider was number 1 in diagnostic testing over a period of time.
So what happened was the patients started to complain, look, I'm still in the office waiting
for this guy to see me I'm only in his office for 2 or 3 minutes why am I being charged all
of a sudden a higher rate most of the time and why are these tests being ordered for all
of us all of the time the same way over and over again?
So the patients complained we interviewed the ultrasound technicians they said, yup,
we're scared to death, you know, we don't feel like we're trained properly
to do the work the equipment doesn't work half the time I can't do a read renal artery study I
can't even find a renal artery yet an interpretation shows
up on the desk they said I found a renal artery and it's 30%, 40%, 50% stenos, right,
and they were getting scared that this would generate additional unsafe medical procedures
on more people.
The office created false medical notes to prepare for their audits by Medicare,
they hid and destroyed documents in response to our subpoenas, they considered burning
down their practice, right, and we proceeded with a full investigation did a search
and the physician obviously went to jail was charged and was excluded.
One thing I'd like to say when you do your audits look at numbers definitely look
at medical charts in reviews but don't forget to talk to people; that's what we do, right,
talk to the technicians make sure the equipment works properly look at the equipment records
for certain testing make sure that you can get the printouts make sure the doctor's paying
for that expensive paper to print out the results so people can read it the right way.
Talk to people don't just rely on medical reviews and desk reviews get out
and talk to the people that are involved.
Spencer asked me to talk about some recent fraud trends
in our region I'll discuss a couple briefly.
Drug diversion, right, I consider it a public health problem and a fraud problem.
Now, the abuse of RX drugs is definitely an epidemic here
in the U.S. the drugs are cleaner they're manufactured
with good manufacturing practices they're inspected by the FDA
and you can get the same affect when you take them on the street as some of the elicit drugs
and it's creating addicts and I have children we all do and it's getting in the hands
of children causing all other sorts of criminal enterprises and crimes on the street.
Doctors are writing scripts for no legitimate medical purpose they're selling the scripts.
Beneficiaries of our programs are going to fill them.
Medicare and Medicaid Part D and Part B are paying for these claims;
they turn them over to other people, runners who sell them on the street.
In many instances the beneficiaries are getting paid just to go
in to the pharmacy fill the scripts, go to the doctor, go in the pharmacy fill the scripts
and turn it over; they make money by participating in that scheme.
Recent case in Philadelphia Doctor Lawrence McCiddy [assumed spelling] was sentenced
to 7 years in prison for doing just that.
This guy had been excluded twice once for a Medicaid fraud in Hawaii once for defaulting
on a HEEL [phonetic spelling] Loan and then he came and set up a cash business
in Philadelphia got involved in this prescription drug scam made a lot
of money then found himself in jail.
Transportation fraud, not everyone who needs renal dialysis qualifies
for a Medicare reimbursed ambulance trip.
Beneficiaries are getting paid.
We found a couple of Craig's List articles out there recruiting beneficiaries,
we'll pay you $200 if you have dialysis and are covered by Medicare or Medicaid
and you want an ambulance ride right on Craig's List.
We're seeing unnecessarily ambulance trips for people who can easily ambulate.
Just 1 Medicare patient, dialysis patient transported 3 times a week for a year brings
in tens of thousands of dollars to an ambulance company,
and when it's unnecessary that's a lot of money going out the door.
Recent examples of indictments in Philadelphia a couple ambulance providers were recently
indicted one was an excluded provider he was involved
in a fraudulent ambulance company years ago was excluded was prosecuted had [inaudible]
and he got back in the business and we believe is operating
or had operated again in another ambulance company.
Unnecessary cardiac stints and we're seeing it in the news here in Maryland;
this is being kicked out by corporate compliance people at hospitals
and for surgery groups and peer groups.
We've seen it in Maryland and a hospital just out in Pennsylvania just turned
over a cardiologist who's accused
of placing unnecessary cardiac stints risky invasive procedures arguably
that weren't necessary and that were just for the money.
ID theft we heard Peter and Spencer talk about that a little bit.
I can't tell you the stack of hotline complaints that are on my desk right now
where people are calling Medicare beneficiaries claiming to be from a diabetic equipment company
and asking to get medical provider numbers, dates of birth,
and information from people either a company trying to steal business, gain business,
or they're using it for credit card fraud or they may be using it to set up one
of these falsified providers that we're looking at.
So we're seeing more examples of excluded providers getting back into the program.
Help us keep the excluded providers out check the LEIE, ask people when they come
in have you ever been excluded, ask them, right, because the LEIE people change their names,
dates of birth, ask them and put that in your personnel files.
Ask them if they have any adverse actions related to healthcare fraud.
These individuals have been excluded for a reason so help us keep them out
and from violating the terms, and then go ahead and check our fugitive website, right,
see if you see those people around.
We don't want to hire any of those people either.
Protect information I mean we all know that protecting the integrity and privacy
of patient information is not only vital to the medical care of a person
but it keeps blatant offensive fraud schemes from reoccurring and occurring.
These criminals use every trick in the book to illegally gain patient
and physician information not just patient information but physician information to set
up completely false front providers.
They trick us into thinking they're legitimate they know how to file clean claims
and they proceed to steal our money and the money's electronically put in the bank account
and then it's gone it's cyberspace bank robbery is what it is and it happens fast.
So continue to make sure all your medical information is protected.
CMS is keeping track of compromised beneficiaries and compromised patient lists
and we're using that and we are exposing these schemes and catching people.
We just arrested a group of people in one of our states in our region.
Within 2 weeks they set up about maybe 10 false companies and billed close to $5 million
in Medicare claims, but we got them and arrested them even before they were paid we hope
and believe.
So, finally, if you uncover a fraud scheme within your practice or entity report it
to our hotline 1-800-HHS-TIPS or through your departments and make the right choice
of how you want to disclose that to either the OIG or the Department of Justice or through CMS;
these actions will demonstrate your continued and full compliance and commitment
to healthcare fraud and enforcement and they will save our programs and protect our citizens
from fraud, insufficient care, and harmful medical practices.
Thank you very much.