Literature Review

Chicago laboratory owner charged with defrauding Medicare in $60 million COVID-19 test kit scheme JD Supra; by Randall Brater, M.H. Joshua Chiu, Michael Dearington, Rebecca Foreman, Nadia Patel, D. Jacques Smith, Hillary Stemple; 6/17/24 The Chicago-based owner of two laboratories, Zoom Labs Inc. and Western Labs Co., has been charged with health care fraud and money laundering in connection with more than $60 million in Medicare claims for over-the-counter (OTC) COVID-19 test kits, including tests delivered to thousands of deceased beneficiaries. Federal prosecutors began investigating Medicare claims from Syed S. Ahmed’s two laboratories after noticing a “massive spike” in the laboratories’ claims in 2023, which coincided with Ahmed assuming control of Zoom [Labs]. ... Ahmed is charged with health care fraud under 18 U.S.C. § 1347 and money laundering under 18 U.S.C. §§ 1956 and 1957. 

CMS recalculates Medicare Advantage star ratings Becker's Payer Issues; by Rylee Wilson; 6/13/24CMS has recalculated Medicare Advantage plans' star ratings after insurers challenging the agency's methodology were handed court victories. In a memo sent to MA plans on June 13, the agency said it would recalculate plans' star ratings for 2024 without eliminating extreme outliers.  

Care provider to pay $14.9M over false claims involving assisted living communitiesMcKnight's Senior Living; Kimberly Bonvissuto; 6/10/24A chronic disease management provider will have to shell out $14.9 million over allegations related to false claims involving assisted living communities, memory care communities and group homes. Bluestone Physician Services of Florida LLC, Bluestone Physician Services PA of Minnesota and Bluestone National LLC of Wisconsin agreed to a $14.9 million settlement with the Justice Department. The federal government alleged that Bluestone knowingly submitted false claims to Medicare, Medicaid and TRICARE — the healthcare program for active duty service members and their families — for certain evaluation and management codes for services related to chronic care management of assisted living residents. The settlement agreement resolves allegations that Bluestone submitted “inflated” claims between Jan. 1, 2015, and Dec. 31, 2019, that did not support the level of service provided. The federal government will receive $13.8 million from the settlement, with more than $1 million going to the states of Florida and Minnesota.

Got questions about Medicare hospice services? Here are some answers Forbes; by Diane Omdahl; 6/11/24 Learning about services that Medicare covers, and their cost, is an important discussion topic for Medicare beneficiaries. However, there is one subject that rarely comes up: hospice, end-of-life care for the terminally ill. ... Perhaps a brief Q&A can plant the seed so those who may face an end-of-life situation in the future will know that hospice can help. 

Five arrested over 'sham hospices' alleged to bilk Medicare for over $15 million Los Angeles Times; by Emily Alpert Reyes; 6/8/24 Angeles over an alleged scheme to bilk the Medicare program of more than $15 million. The U.S. Department of Justice said three of the San Fernando Valley residents who were arrested — Petros Fichidzhyan, also known as Peter; Juan Carlos Esparza; and Karpis Srapyan, also known as Tony Levy — were accused of running "sham hospice companies" and turning in fraudulent claims to Medicare for hospice services. ... As part of the alleged scheme, the three defendants misappropriated the identifying information of doctors to claim those physicians had deemed hospice services necessary for patients, federal prosecutors said. They also allegedly used the names and Social Security numbers of Russian and Ukrainian citizens who had left the U.S. to open bank accounts and sign leases, indicating that the "impersonated identities" were the owners of the hospice companies that they in fact controlled, according to the federal indictment. 

Kickbacks and medically unnecessary treatments: Five major qui tam settlements from May 2024 JD Supra; by Geoff Schweller; 6/5/24 Under the FCA’s qui tam provisions, a crucial tool in combating healthcare fraud, whistleblowers have the power to file suits on behalf of the federal government if they possess the knowledge of an individual or company defrauding the government. The government may choose to intervene and take over the suit, but if a qui tam lawsuit results in a successful settlement, the whistleblower is eligible to receive between 15-30% of the monies collected. The settlements announced in May cover a wide range of alleged misconduct that violates the FCA, including cases concerning kickbacks and the billing of federal healthcare programs for medically unnecessary treatments. Each settlement represents a victory in the ongoing battle against fraud. ... [Non-hospice examples followed by this hospice case] $4.2 Million Settlement with Elara Claring for Allegedly Billing Medicare for Ineligible Hospice Patients ...

Proposed HOPE tool seeks to fill hospice data gaps but needs tweaking, experts sayMcKnight's Home Care; by Adam Healy; 6/3/24Although the proposed Hospice Outcome and Patient Evaluation (HOPE) tool intends to close important data gaps surrounding end-of-life care, there is more work to be done to improve hospice quality reporting. “So much more information needs to be gathered from these patients,” Katy Barnett, director of home care and hospice operations and policy at LeadingAge, the association of nonprofit aging services providers, which include hospices, told McKnight’s Home Care Daily Pulse in an interview. “It’s just not there in the tool right now.”

SCAN wins Medicare Advantage star ratings lawsuit against CMSModern Healthcare; by Nona Tepper; 6/4/24SCAN Health Plan has prevailed in a widely watched federal lawsuit brought last year against the Centers for Medicare and Medicaid Services that alleged regulators did not appropriately calculate the insurer's Medicare Advantage star rating. The decision could have industrywide implications for the star ratings program if regulators decide to recalculate all carriers’ star scores for the 2024 plan year. The ruling could also affect several pending cases filed by other insurers against CMS. It also could be appealed.

Joel Mekler - Medicare Moments: Watch out for these latest scams New Castle News; by Joel Mekler; 6/3/24 ... Across the country, many unscrupulous hospice providers are recruiting and enrolling nonterminally ill patients for end-of-life care they do not need and then billing Medicare for services and items they may never receive. They trick beneficiaries into signing up for hospice by offering freebies, such as additional groceries, nurse visits, durable medical equipment, bus coupons, and more once they enroll. They also make false claims, such as saying “Medicare now covers cooking and cleaning services”. Or they tell beneficiaries they qualify due to age, saying “You’re now old enough to qualify for hospice!” Another tactic is giving money, with some recruiters telling beneficiaries, “You can earn $400/month if you agree to enroll in our program.” ... Tips [to consumers] to avoid hospice fraud:

Hospice Certifying Physician edit in effectAAPC - American Academy of Professional Coders; by Rebecca Johnson; 6/3/24 The Centers for Medicare & Medicaid Services (CMS) and its Home Health and Hospice (HHH) Medicare Administrative Contractors (MACs) are all systems go for the new — and potentially troublesome — claims system edit. The edit went into effect June 3. ... In the 2024 Hospice Payment Rate Update final rule, CMS adopted a requirement that two categories of physicians must be enrolled in or validly opted out of Medicare for hospice services to be paid: the hospice medical director or the physician member of the hospice interdisciplinary group; and the attending physician that certifies the patient for hospice. CMS did at least grant hospices’ requests for an implementation delay at that time, moving the deadline from the proposed Oct. 1, 2023, to May 1, 2024. Then, on the eve of that start date, CMS bumped the edit for one more month. ...

NHPCO: CMS did not account for full burden of implementing HOPE Tool Hospice News; by Jim Parker; 5/29/24 The U.S. Centers for Medicare & Medicaid Services (CMS) may not have accounted for the financial and administrative burdens associated with its implementation of the Hospice Outcomes and Patient Evaluation (HOPE) Tool. In comments on the 2025 proposed hospice rule, the National Hospice and Palliative Care Organization (NHPCO) voiced concerns that the agency’s regulatory impact assessment may not have taken all the details into account, including the need for staffing and technology investments. “Clinical and administrative cost calculations do not align with the reality of the true costs of implementation,” NHPCO indicated in a letter to CMS. “In the proposed rule, CMS significantly underestimated the burden and costs hospices will incur to comply with HOPE requirements. The agency’s estimated cost burden of approximately $185 million across all hospices fails to account for several important factors.”

Hospice Owner Sentenced to 240 Months Imprisonment and Ordered to Repay $42,000,000 for Defrauding MedicareDepartment of Justice; 5/16/24New Orleans - U.S. Attorney Duane A. Evans announced that on May 15, 2024, U.S. District Judge Lance Africk sentenced SHIVA AKULA (“AKULA”), age 68, of New Orleans, to 240 months of imprisonment, three years of supervised release and $2,300 in mandatory special assessment fees, in relation to an extensive health care fraud scheme orchestrated by AKULA. In November 2023, a federal jury convicted AKULA of all 23 counts of his underlying indictment. AKULA owned and oversaw the day-to-day operations of Canon Healthcare, LLC, a hospice facility with offices in the New Orleans area, Baton Rouge, Covington, and Gulfport, Mississippi. At sentencing, the Court found that between January 2013 and December 2019, Canon billed Medicare approximately $84 million in fraudulent claims and was paid approximately $42 million relating to these fraudulent claims. The Court ordered that AKULA repay the $42 million of fraudulent proceeds back to Medicare.

Compliance Strategies for Forthcoming Hospice HOPE ToolHospice News; by Holly Vossel; 5/16/24Hospices will have a learning curve when it comes to implementing the Hospice Outcomes and Patient Evaluation Tool (HOPE) tool. The U.S. Centers for Medicare & Medicaid Services (CMS) is currently developing quality measures that will be included in the HOPE tool, which will replace the current Hospice Item Set (HIS). After years of development, the agency in its recent hospice proposed rule indicated that the HOPE tool’s implementation would begin in 2025.Notable Mentions: Jennifer Kennedy, CHAP; Kimberly Skehan, CHAP.