lisa re of hhs powerpoint presentation with her speech on medicaid and medicare provider exclusions

7/30/2019 Lisa Re of HHS Powerpoint Presentation with her speech on Medicaid and Medicare Provider Exclusions

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Office of Inspector General

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OIG Corporate IntegrityAgreements, Exclusion Lists & Communication Requirements


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Overview

OIG Exclusion AuthoritiesExclusion Referrals to OIGQuality of Care Enforcement Cases

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CIAs


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What is Exclusion?

Effect of ExclusionRemedialProtect Federal health care programs

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and beneficiariesPermissive v. Mandatory


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Exclusion Authorities

Mandatory Exclusion criminal conviction Permissive Exclusion- 15 authorities

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http://oig.hhs.gov/fraud/exclusions/authorities.asp


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Referral Sources

USAOsMFCUsLocal prosecutors

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State Medicaid AgenciesLicensing boards


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Should you refer a case to OIG formandatory exclusion?

Was there a criminal convictionrelated to

Medicare or Medicaid fraud?

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Patient abuse or neglect?Felony health care fraud?Felony controlled substance?


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Should you refer a case to OIG forpermissive exclusion?

Was there a criminal convictionrelated to

Fraud related to a health care

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program opera e y e era ,State, or local government agency?Obstruction of an investigation?

Misdemeanor conviction relating tocontrolled substance?


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When to report convictions

Report convictions as soon asdefendant is sentenced even if appealed

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Referrals to the OIG Regional Office


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Documentation

JudgmentPlea agreementIndictment, information, etc.

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,necessaryAggravating factors

Mitigating factors (includingcooperation)Cover letter with a brief summary


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License revocation orsuspension?

1128(b)(4)Individual or entityLicense has been revoked, suspended,

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Professional competence, professionalperformance or financial integrity

Length of exclusion indefinite1128(b)(4) - eligible for reinstatementonce license is reinstated


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When and what to report

Report as soon as the Board hastaken final actionDocumentation requirements

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Final action and supportinginformation


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How do you know if someone isexcluded?

List of Excluded Individuals/Entities(LEIE)

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http://oig.hhs.gov/fraud/exclusions.asp


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GovernmentEnforcement of Quality of Care

Enforcement priorityDOJ, OIG, Medicaid Fraud ControlUnits

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r m na , c v , an a m n s ra vecasesCorporate Integrity Agreements

(CIAs)Inter-governmental training,collaboration and monitoring


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Federal Prosecution Theories

Criminal ViolationsHealth care fraudFalse statements related to health care

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Mail fraud, conspiracyCivil False Claims

False ClaimsExpress or implied certification of compliance with statute or regulation


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Federal Prosecution Theories(cont.)

Administrative Sanctions

Worthless Services theory

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Civil monetary penalties


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Failure of Care/WorthlessServices

Knowingly requesting payment forgoods or services that were:

Provided in a grossly deficient

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mannerKey question: Did the governmentreceive value for the bundle of services for which it paid?


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When Does a Failure of Care Equal a Worthless Service?

Evidence of care so egregious it isworthless, or worse

Systemic or widespread problems

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Evidence of harm to patients


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What Does ThisMean in Plain English?

Providers that:knowingly render grosslysubstandard or no care

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harm or kill patients (not a requiredelement, but usually present), andbill Medicare or Medicaid for thealleged care

May be pursued under the FalseClaims Act


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OIG Exclusion AuthoritiesRelated to Quality of Care

Social Security Act 1128 (42 U.S.C.1320a7)Mandatory exclusion

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neglect

1128(a)(2)Permissive exclusionsLicense revocation

1128(b)(4)


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OIG Exclusion AuthoritiesRelated to Quality of Care (cont.)

Items or services provided in excessof the patients needs

1128(b)(6)(B)

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Items or services which fail to meetprofessional standards1128(b)(6)(B)

False or fraudulent claims1128(b)(7)


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OIGs Role in Failure of Care Cases

Investigate failure of care allegations

Work on civil and criminal prosecutions

Exclude a ro riate individuals and

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entitiesNegotiate Quality of Care CIAs aspart of the settlement of False ClaimsAct cases

Monitor implementation of CIAs


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Guideposts for Prosecution

Was there a systemic failure toaddress quality issues?Did the organization make false

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Did the organization profit fromignoring poor quality?

Have patients/residents been harmedby poor quality?


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Types of Cases DOJand OIG do NOT Pursue

DOJ and OIG do not . . .

Bring malpractice cases

But malpractice cases are not a bar

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to government casesBring administrative cases to enforcesurvey results

But survey findings may be someevidence in an enforcement matter


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Martha Bell and Atrium INursing Home (2005)

Pennsylvania nursing home and itsadministrator

Allegations:Falsification of medical records and billing

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recor sSubstandard care egregious; residenteloped and diedInvoluntary Manslaughter, Neglect Care of

a Dependent Person, RecklesslyEndangering Another Person, CriminalConspiracy to Tamper with PhysicalEvidence


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Martha Bell and Atrium INursing Home (cont)

Results:First Trial, Health Care Fraud (2005)

Bell: 60 months in prison, $50,000 fine

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Atrium: 5 years of probation, $490,000fine

Second Trial, Cover-Up, InvoluntaryManslaughter, etc. (2007)

Bell: additional 22 to 44 months inprison


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Cathedral Rock (2010)

Texas corporation, operated nursinghomes in 4 states (25 facilities in2004, 15 facilities in 2010)

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A egations:Substandard care resulting in deaths andserious injuries

Falsification of residents medical records


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Cathedral Rock (2010) (cont.)Results:

Settled FCA liability for $628,0005-year CIA

1 000 000 in criminal fines and enalties

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Corporate officer and owner C. KentHarrington entered into two-year DPA


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FORBA Holdings Small Smiles Centers (2010)

Nationwide chain of pediatric dentalclinics (68 clinics)

Allegations:

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Substandard careMedically unnecessary services

Pulpotomies (baby root canals),

extractions, anesthesia, etc.


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FORBA Holdings Small Smiles Centers (2010) (cont.)

Results:Settled for $24 million, plus interest

5-year CIA

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Chief Dental Officer

Independent Monitor


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Emmanuel Bernabe (2009)

President and sole owner of a largeCalifornia nursing home chain (29+facilities)

Alle ations:

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Substandard careFailure to protect residents from accidents,neglect, abuse, etc.Chronic understaffing

Result:Permanent Exclusion


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Signs of Quality ProblemsFinancial, rather than clinical factors driving

decisions about:Admissions/censusBonuses and compensation

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Training, data collection and management

Too few staff, lack of staff competencyLack of focus on quality outcomes, process,culture, and dataFailure to monitor and evaluate problemsas they arise


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Quality of Care CIAs28 Quality of Care CIAs (as of 3/22/10)

Different from other CIAsIndependent Monitor

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ua ity Assurance Monitoring ommittee

Internal Audit Requirements

Extensive policies and procedures

Intensive training requirementsReporting


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Purpose of Quality of Care CIA

Focus on systemic issues, notindividual problemsFocus on providers internal system of

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quality assurance and improvementCross state boundaries with chain-wide perspective

Role of the Independent Monitor


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CIAs are publically available

http://oig.hhs.gov/fraud/cias.asp

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Contact InformationLisa Re

Deputy Chief

Administrative & Civil Remedies Branch

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Department of Health & Human Services202-205-9213


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HeadquartersExclusions Staff

Maureen R. Byer

Director

HHS/OIG/OI

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xc us ons aSuite 2107175 Security BoulevardBaltimore, MD 21244

410-281-3060


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OIG Regional OfficesBoston

Connecticut, Maine,Massachusetts, New Hampshire,

New York

New Jersey, New York,PuertoRico, Virgin Islands

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,

HHS/OIG/OIRoom 2475JFK Federal Building

Boston, MA 02203

617-565-2664

HHS/OIG/OIRoom 13-12426 Federal Plaza

New York, NY 10278

212-264-1691


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OIG Regional OfficesPhiladelphia

Delaware, District of Columbia,Maryland, Pennsylvania,Virginia, West Virginia

Atlanta

Alabama, Georgia,Kentucky, Mississippi,North Carolina, South

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HHS/OIG/OISuite 326150 South Independence Mall

West

Philadelphia, PA 19106215-861-4586

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HHS/OIG/OISuite 5T1861 Forsyth Street, SWAtlanta, GA 30303

404-562-7603


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OIG Regional OfficesChicago

Illinois (except centraland southern), Indiana,

Michigan,

Dallas

Arkansas, Louisiana, NewMexico, Oklahoma, Texas

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, ,

HHS/OIG/OISuite 1330233 North Michigan Avenue

Chicago, IL 60601312-353-2740

HHS/OIG/OIRoom 6291100 Commerce Street

Dallas, TX 75242

214-767-8406


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OIG Regional OfficesKansas City

Colorado, Illinois (central andsouthern), Iowa, Kansas,Missouri, Montana, Nebraska,

San Francisco

Alaska, Northern California,Idaho, Oregon, Washington

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North Dakota, South Dakota,Utah, Wyoming

HHS/OIG/OISuite 920

1201 WalnutKansas City, MO 64106

816-426-4000

HHS/OIG/OISuite 3-510

90 7th StreetSan Francisco, CA 94103

415-437-7961


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OIG Regional OfficesLos Angeles

Arizona, Southern California,Guam, Hawaii, Nevada, Samoa,Wake Islands

Miami

Florida

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HHS/OIG/OISuite 1100600 West Santa Ana BoulevardSanta Ana, CA 92701

714-246-8302

HHS/OIG/OISuite 3068100 Oak LaneMiami Lakes, FL 33016

305-530-7756

lisa re of hhs powerpoint presentation with her speech on medicaid and medicare provider exclusions

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