Articles Posted in Health Law

By Adrienne Dresevic, Esq. and Carey Kalmowitz, Esq. of The Health Law Partners, P.C.

The Centers for Medicare & Medicaid Services (CMS) issued a final rule that strengthens the agency’s ability to stop fraud by barring unscrupulous providers out of federal health insurance programs. This rule is unlike past rules in that it stops providers before they get paid. This is a momentous step on CMS’s part to end “pay and chase” in federal health care fraud efforts and replace it with proactive measures.

The final rule, Program Integrity Enhancements to the Provider Enrollment Process (CMS-6058-FC), becomes effective November 4, 2019 and establishes novel revocation and denial authorities to buttress CMS’ efforts to stop waste, fraud and abuse. This rule is applicable to the entire provider community, including radiologists.

An Ashland, KY addiction treatment specialist, Dr. Rose O. Uradu, and her substance abuse treatment center, Ultimate Care Medical Services, LLC d/b/a Ultimate Treatment Center, have agreed to pay $1.4 million to resolve civil allegations that they violated the Controlled Substances Act, and defrauded the Medicare and Kentucky Medicaid programs.

The settlement resolved a civil lawsuit alleging that Ultimate Treatment Center, at the direction of Dr. Uradu, sought and received payments from Medicare and Kentucky Medicaid for services that were not actually provided to patients. According to the Complaint, between January 2013 and September 2014, defendants billed these government programs for “evaluation and management” services, purportedly provided to patients who visited the clinic to receive daily methadone doses. The United States alleged that Ultimate Treatment Center did not actually perform these services when patients received their methadone doses, but falsely documented the performance of these services, in the patients’ medical records, in order to create the false appearance that the reimbursement was justified.

The United States further alleged that, during the period July 2013 and December 2014, defendants billed Medicare and Kentucky Medicaid for complex urine testing that the clinic’s equipment was incapable of performing, therefore violating the False Claims Act.

On July 30, 2019, a federal jury in Detroit, Michigan, found a patient recruiter guilty for his role in a scheme involving approximately $1.3 million in fraudulent Medicare claims for home health care that were procured through the payment of illegal kickbacks.

Following a six-day trial, Dominic Trumbo, 45, of Lexington, Kentucky, was found guilty of one count of conspiracy to pay and receive health care kickbacks and three counts of receipt of health care kickbacks.

According to evidence presented at trial, from 2009 to 2017, Trumbo, owner of Trumbo Consulting Agency, solicited and received kickbacks in exchange for referring Medicare beneficiaries to serve as patients at multiple home health agencies. These agencies then submitted claims to Medicare for home health services that were purportedly provided to those beneficiaries.

This year, key information regarding the Appropriate Use Criteria (AUC) program is being released by the Centers for Medicare & Medicaid Services (CMS) via guidance documents. A Change Request was issued July 26, 2019, informing Medicare Administrative Contractors (MACs) that they are to begin accepting AUC-related modifiers and healthcare common procedure coding system (HCPCS) codes in 2020.

Under the AUC program, a practitioner must consult a qualified Clinical Decision Support Mechanism (qCDSM) at the time of an advanced diagnostic imaging service order. The qCDSM – an electronic portal through which AUC is accessed – provides a determination of whether the order adheres to AUC or if the AUC consulted was not applicable to the patient’s clinical condition.

Currently running as a voluntary program, CMS has announced an Education and Operations Testing Period to begin January 1, 2020 and running the full calendar year to give practitioners appropriate time to adjust to the system. During this period, “claims will not be denied for failing to include AUC-related information or for misreporting AUC information.” However, CMS also writes that they expect ordering professionals to begin consulting qCDSMs and providing the relevant information to the furnishing providers during the test period “as it is important for CMS to track this information.”