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