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Hospital Pays $3.77 Million to Settle Allegations as Medicare Continues Fraud Crackdown

Written by Rob Kurtz
Tuesday, 11 March 2008
Yale-New Haven (Conn.) Hospital became yet another hospital to agree to a multi-million dollar fine to settle allegations by CMS that it billed Medicare for inflated charges, the U.S. Attorney's Office, District of Connecticut announced on Friday. The case is part of the agency's continuing efforts to target organizations attempting to defraud the Medicare program.
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Perpetrators in Two Medicare Fraud Schemes Sentenced, Convicted

Written by Stephanie Wasek
Monday, 10 March 2008
The Medicare Fraud Strike Force continues to make its mark, with two big announcements in South Florida cases Friday. First, the perpetrator of a $48 million Medicare durable equipment billing fraud was sentenced to 19 years in prison and ordered to pay more than $7.2 million in restitution to the Medicare program and to pay a nearly $7.9 million money judgment, the U.S. Attorney's Office, Southern District of Florida announced. Second, a physician and the owner-operators of two durable medical equipment companies and a home healthcare agency were convicted by a federal jury, the U.S. Department of Justice announced. Since March 1, 2007, the Strike Force has brought charges against 120 defendants, resulting in 101 convictions.
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Justice Department Subpoenas Stryker Over Foreign Practices

Written by Rob Kurtz
Thursday, 06 March 2008
Device maker Stryker Corp. has announced that it received a subpoena from the criminal division of the Department of Justice requesting documentation concerning possible violations of the Foreign Corrupt Practices Act, which prohibits bribing officials to obtain or retain business.
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The Empire Strikes Back: N.Y. Probes Underpayments by Insurers to Out-of-Network Providers, Patients

Written by Stephanie Wasek
Thursday, 21 February 2008
After several years of insurance companies aggressively setting limiting rates as to what they will pay out-of-network providers, New York has launched an investigation into whether insurance companies are unfairly setting those rates and causing patients to pay disproportionately high amounts of provider bills. Health insurers are being probed as part of an healthcare industry-wide investigation to determine whether they have schemed to "defraud consumers by manipulating reimbursement rates," according to the N.Y. attorney general's office. A six-month investigation found that Ingenix, the nation's largest provider of healthcare billing information, "operates a defective and manipulated database that most major health insurance companies use to set reimbursement rates for out-of-network medical expenses." Further, the investigation found that two subsidiaries of United "dramatically under-reimbursed their members for out-of-network medical expenses by using data provided by Ingenix," according to a release.
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Orthopedic Device Makers Reveal Consultant Payment Info; OIG to Examine Physician Liability

Written by Scott Becker
Friday, 18 January 2008
Now that five orthopedic device manufacturers have disclosed their financial relationships with physicians, the OIG says it will be using this information to "determine whether some doctors could be liable in accepting illegal payments from those manufacturers," according to a report from BNA Health Care News.
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New Jersey Adopts Emergency Amendment on Physician-Ownership

Written by Scott Becker
Friday, 18 January 2008
The New Jersey Board of Medical Examiners, on the heels of an interesting case related to the Codey Act (the details of which you can view here), has issued an emergency amendment on physician-ownership. The amendment will require all qualifying practitioners and practices to adhere to disclosure-of-ownership requirements within 120 days of the amendment's effective date; it has been adopted on an emergency basis and will become effective upon acceptance for filing with the state Office of Administrative Law.
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Orthopedic Industry News: Imaging and Device Slowdown; Physician Prescription Info Law Nixed

Written by Scott Becker
Friday, 18 January 2008
Changes in the Imaging and Medical Device Industry. The Wall Street Journal recently noted that each of Phillips, Siemens and General Electric is reporting reduced sales on items such as CT and MRI machines. This slowdown is due in part to reduced reimbursement from the government for non-hospital-site imaging. There is some expectation that this slowdown will last for a long time. Further, there is increased pricing pressure on the private and commercial payor sides. In reviewing this situation, the Wall Street Journal has reported that Phillips plans to change its business strategy to more fully attempt to grow its international business as opposed to staying as highly focused in the United States for CT and imaging business development. GE and Siemens have been less committal about potential changes in strategy.
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Ruling in La. Suit Boost for Out-of-Network Providers

Written by Scott Becker
Friday, 18 January 2008
A recent Federal Appellate Court Ruling from the 5th District regarding a dispute between Blue Cross and some hospitals in Louisiana sets a positive precedent for out-of-network providers and payments. The case started when two hospitals -- who had terminated their Blue Cross contracts due to too-low reimbursements -- filed a complaint with the Louisiana Department of Insurance against the company. In response, Blue Cross sent payment checks directly to patients for services provided by the two hospitals, forcing them to pursue patients for reimbursement -- a difficult task.
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The Tax-Exempt Board Fiduciary Duties in the Context of Evaluating Strategic Alternatives and Sales

Written by Scott Becker
Friday, 18 January 2008
A recent New York State hospital transaction highlights the challenging problem which the Board of Directors of a not-for-profit institution faces in the context of a sales transaction.¹ In Manhatten Eye, Ear & Throat Hospital ("MEETH"), the Court denied the petitiion for judical authorization to sell substantially all of the assets of the Manhatten Eye, Ear & Throat Hospital. The Court held that the Manhatten Eye, Ear & Throat Hospital Board had not fulfilled its duties to the not-for-profit corporation. In contrast to a number of other cases involving the sale of not-for-profit assets, the Board was not criticized for failing to find the highest bidder for entering into self-dealing or self-interested transactions. Rather, the Board was criticized for not fulfilling its "duties of obedience" to the corporation's charitable purposes.
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