Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

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The Week That Was in Healthcare Fraud and Legality

By Ryan Mcaskill

A recap of high-profile charges, convictions and sentencing involving healthcare legality ending the week of January 23, 2015.

- The United Stated Department of Justice has put a stop to a number of different high-value healthcare scams and charged, convicted or sentences several physicians and executives. The charges resulted in multiple millions of dollars in fraud and months in jail.

Here is a roundup of some of the legal dealings from the past week.

Former Clinic Operator Pleads Guilty to $12 Million Medicare Fraud

Jorge Juvier plead guilty in Manhattan federal court to participating in a plan to defraud Medicare of more than $12 million. This was done through HIV/AIDS clinics in New York City. Juvier and his partners billed Medicare for medications that were never distributed, were administered in incorrect doses or were medically unnecessary.

Between 2010 and 2013, the team of co-conspirators recruited HIV.AIDS patients who were eligible for Medicare to visit clinics multiple times a week for months to indore treatments that were often not necessary. They also paid some patients a $300 per week kickback in exchange for coming to the clinic and receiving treatment.

Medicaid Billing Probe Finds $3.65 Million Discrepancy

The Sea Mar Community Health Centers in Seattle, Washington, has agreed to pay $3.65 million to settle charges of improper Medicaid billings. The two and a half year investigation was run by the state Attorney General’s Office and found that the provider overbilled Medicaid for thousands of dental appointments between 2010 and 2014.

The issue came from fluoride treatments, which are typically performed by a dental assistant as part of regular checks. It should cost $13.25 for most adults and $23.41 for younger children. However, these were billed as “encounters” with a dentist that has a higher price tag of $180.

Hospital Pays $1.775 Million for Kickbacks

The South Shore Physician Hospital Organization (SSPHO) in South Weymouth, Massachusetts will pay $1.775 million to settle allegations of operating a recruitment grant program that paid kickbacks to its physician members in exchange for patient referrals.

It was alleged that between 2001 and 2010, SSPHO approved 103 separate recruitment grants to 33 different physician groups.

“Instead of giving patients lower cost options and flexibility in health care services, we allege these defendants looked to increase their referrals through an unlawful kickback operation,” Massachusetts Attorney General Martha Coakley said.  “We are pleased to have worked with our partners in federal law enforcement to ensure that improper incentives do not undermine the integrity of our healthcare system.”

Texas Chiropractor Sentenced in Healthcare Fraud Case

Melva Mitchell, a licensed chiropractor, was sentenced to to 12 months and one day in federal prison and ordered to pay $126,048 in restitution to Medicare and Medicaid for making false statements relating to healthcare matters.

While operating Best Choice Chiropractic and Wellness Center in Fort Worth, Texas, Mitchell submitted claims for reimbursement to Medicare and Medicaid for services that were not performed. She obtained provider information for other occupational therapists and used it to illegally obtain payments.

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