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Robert Church

United states, United States

SME-Healthcare Fraud, False Claims Act, Antikickback, Financial Forensics/Accounting, Tax Crimes.

Robert ChurchPoints
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Author14
Influencer10
Speaker0
Entrepreneur0
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Thought Leader Profile

Portfolio Mix

Company Information

Areas of Expertise

COVID19 31.16
Health and Safety 33.89
Health and Wellness 30.79
Healthtech 32.20
Legal and IP
Business Continuity 30.39
Marketing 30.10
Mental Health 30.96

Industry Experience

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14 Article/Blogs
Virginia-Based Family Medical Practice Agrees to $2.15 Million Settlement for Violating False Claims Act
Thinkers360
July 27, 2021

A Virginia-based company recently agreed to a $2.15 million civil settlement with the state attorney general of and the U.S. Attorney's office.

Allergy and Asthma Associates Inc., based in Roanoke, will pay the money after allegedly billing Virginia Medicaid and Medicare programs more than $600,000 for asthma treatments it either never purchased or administered in an improper way to their patients.

The medical practice that is family owned pleaded guilty in Roanoke's U.S. District Court back in June of 2020 to one criminal count of health-care fraud.

Court documents say that between January of 2010 and September of 2017, the company submitted billings to both Medicaid and Medicare. The improper billings were for Xolair, which is a single-use asthma treatment that is quite expensive.

Because of the drug's nature, many patients need to receive doses with the help of health-care providers administering only part of the vial. This, in turn, leaves unused leftovers of Xolair that the provider doesn't administer to the patient.

Rules under Medicaid and Medicare sometimes allow for providers of the drug to bill Medicaid and Medicare Part B once for a full vial of the drug. This would include the quantity that was administered to the patient as well as the amount that had to be discarded. The two must add up to the amount that's listed on the label of the vial.

What AAA allegedly did was take the leftover Xolair that they had and then administer it to other patients. The company then billed both Medicaid and Medicare for administering the amounts as if they were the full vial, rather than what was used and what was left over.

In the time period alleged, the company billed $627,540 to Medicare for Xolair it never purchased. From Medicaid, the company also received 129 vials of the medication but didn't document it as ever being used for a patient on Medicaid. That resulted in a reported loss of nearly $89,000 for Medicaid.

The total sum that AAA will pay as part of the settlement of claims that they violated the federal false claims act is roughly $2.15 million. Roughly $1.99 million of that will go to the federal government, while a little more than $154,000 will go to the Commonwealth of Virginia.

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Tags: Health and Safety, Healthtech, Mental Health

Manhattan Pharmacy Owner Pleads Guilty to Lying to DEA Agents Regarding Controlled Substances
Thinkers360
July 20, 2021

A former Manhattan pharmacy owner plead guilty to making false statements to Drug Enforcement Agency officers on two occasions regarding possession of controlled dangerous substances.

After selling his pharmacy, Richard Schirripa told DEA officers on two occasions that he had either transferred, destroyed or sold the controlled substances he had. Officers discovered, though, that he still had thousands of these patches or pills, which he was keeping in his home.

The controlled substances that were prescribed to other people included oxycodone and fentanyl. According to court documents, in January of 2020, Schirripa closed his Madison Avenue Pharmacy, which was located in Manhattan. The owner didn't comply with a law that requires all pharmacies to notify the DEA within 14 days of shutting down their operations.

Officers only realized the pharmacy had closed when they were attempting to conduct a routine audit of the facility. When arriving at the location, officers saw a sign in the store window saying Madison Avenue Pharmacy had been closed, and all controlled substances it had were transferred to another pharmacy.

DEA officers then visited that other pharmacy that was specified on the letter. That month, Schirripa wrote to the DEA then met with officers in person in February 2020.

In both instances, Schirripa made false statements to the officers, telling them he either sold, destroyed or transferred all the controlled substances when he closed his pharmacy.

DEA officers discovered that Schirripa had kept in his possession thousands of controlled substances, which he kept in a safe in his Long Island home. An April 2020 search warrant revealed the substances, which Schirripa admitted were from his pharmacy, but he said he was going to destroy them.

DEA officers found almost 4,000 patches or pills, and some had labels indicating they were prescribed to other people.

Schirripa, a 67-year-old man from Fort Salonga, New York, reached a plea agreement in the case. As part of that agreement, he also admitted to regulatory violations about controlled substances. He also agreed to surrender his pharmacy licenses, a three-year ban on re-apply for the license and a three-year ban on employment that would involve him controlling, possessing or distributing any controlled substances.

The one count of making false statements that he plead guilty to has a maximum sentence of five years in prison. Schirripa's sentencing is scheduled for July 13, 2021.

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Tags: Health and Safety, Healthtech, Mental Health

80-Year-Old Physician Sentenced to Five Years in Prison for Role in 'Pill Mill' Opioid Distribution
Thinkers360
July 14, 2021

An 80-year-old suburban Philadelphia doctor was sentenced to serve five years in prison for his role of distributing opioids for non-legitimate medical purposes.

Myron Rodos of Ambler, Pennsylvania, was also sentenced to three years of supervised release and must pay a $300,000 fine for distributing controlled substances.

In November 2019, he pleaded guilty to distributing Schedule II controlled substances. He was charged with four counts of the crime.

In exchange for money and sex, Rodos allegedly distributed 3,670 10-miligram pills of methadone and 6,130 30-miligram pills of oxycodone to patients. The defendant was a physician operating out of a North Philadelphia medical practice at the time he committed the crimes.

That practice has been termed a "pill mill," because the physician prescribed controlled substances that are addictive and dangerous to various patients who are addicts. In many cases, the U.S. Attorney's office alleged that Rodos exchanged the pills for sexual favors.

Jennifer Arbittier Williams, the acting U.S. Attorney on the case, said her office as "committed to stopping drug-dealing doctors like Rodos."

In a statement, she said Rodos knew how dangerous the drugs he was prescribed could be, yet he gave them out anyway to addicts because of his greed.

The special agent in charge of the investigation at the Philadelphia Division of the FBI, Michael J. Driscoll, said it was "hard to understand how a longtime physician, trained to help and to heal people, could be this depraved."

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Tags: Health and Safety, Health and Wellness, Healthtech

Former Administrator at Sister Facility of Brighton Rehabilitation and Wellness Center in Pennsylvania Indicted for Role in Fraud Conspiracy
Thinkers360
July 07, 2021

A 60-year-old former administrator of a rehab and wellness center has been indicted for charges that include health care fraud, defrauding the United States and obstruction of a federal audit.

The investigation into Susan Gilbert, the former administrator at Mount Lebanon Rehabilitation and Wellness Center, is still ongoing. If convicted of all charges, she could face up to 10 years in prison as well as a fine of $250,000. Mount Lebanon is a sister nursing home to Brighton.

A joint investigation by the U.S. Attorney's office as well as the Pennsylvania Attorney General's led to the charges before a federal grand jury.

The allegations are that Gilbert directed various employees to falsify company records so it would look as if the facility met both state and federal staffing requirements.

The indictment alleges that between October 2018 and February 2020, Gilbert led a conspiracy that defrauded Pennsylvania of both property and money. She impaired, impeded, obstructed, interfered with and defeated the governmental functions of the U.S. Department of Health & Human Services in its administration of Medicaid, as well as the Pennsylvania Medicaid program.

She is also alleged to have obstructed the work of a federal auditor as well as committing health-care fraud.

Gilbert was the administration of Mount Lebanon, a skilled nursing home in Allegheny County, Pennsylvania. The facility is part of a larger company that owns various long-term care facilities in the state, which includes the Brighton Rehabilitation and Wellness Center.

According to the indictment, Gilbert and her co-conspirators directed nursing staff at the management and administrative level to "clock in" for shifts they didn't actually work. This led to the company creating falsified timecards, making it appear the individuals were providing direct care to residents when they weren't even in the building.

Those involved include general administrative staff, the assistant director of nursing, and the director of nursing. The staff was coerced into conspiring with Gilbert because they were given monetary bonuses for doing so.

In addition to clocking in for hours they didn't work, the staff was also instructed not to clock out for lunch breaks, which were 30 minutes. They then falsified timecard sheets that were provided to the Department of Health & Human Services.

Gilbert instructed administrative staff to maintain two books that reflected levels of staffing -- one that was accurate with the actual hours worked and one with the falsified information. The falsified book was provided to investigators at the DOH when they conducted inspections that were mandated by federal law.

Gilbert is alleged to have done this with her co-conspirators so the facility would look as if it complied with all conditions for participating in the Pennsylvania and federal Medicaid programs.

One condition is the facility must have "sufficient" nursing staff on hand to meet the needs of residents. Another is the facility was able to operate and provide services that complied with all state, local and federal codes, laws and regulations.

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Tags: Health and Safety, Healthtech, Mental Health

Two Former Owners of Therakos Agree to Settlements for Improperly Marketing Their Products for Use in Pediatric Patients
Thinkers360
July 06, 2021

Two separate multi-million-dollar settlements have been reached between all 50 states and two former owners of Therakos Inc. for improper marketing and submitting falsified claims to state-run Medicaid programs.

The first settlement for $10 million was with Medical Device Business Services Inc., or MDBS, which is a Johnson & Johnson subsidiary. The second is for $1.5 million with The Gores Group, a private equity firm that operates around the globe.

California will receive a little more than $73,000 from MDBS and almost $61,000 from Gores, Xavier Becerra, the state's attorney general, announced.

Beginning 2016, it's alleged that MDBS marketed two separate systems that Therakos produced to doctors. The systems were created to use for pediatric patients, and were marketed as such -- even though the U.S. Food and Drug Administration hadn't approved them for use in pediatric medicine.

Gores acquired Therakos in 2013, and is alleged to have continued improperly marketing the systems after.

UVADEX is a drug Therakos developed to be used with its ECP systems known as CELLEX and UVAR XTS. They were designed to help treat problems of the skin that were associated with CTCL, or cutaneous T-cell lymphoma, which is a form of Non-Hodgkin's lymphoma.

It is a cancer of the immune system where T-cells that are cancerous migrate to the skin. The body will then develop lesions.

The ECP system Therakos developed remove portions of blood in a patient by using centrifugation, the FDA said. Then, the systems separate red blood cells from the layer of white blood cells.

UVADEX is then mixed with this layer of white cells once injected. Ultraviolent light is then used to irradiate the mixture. Finally, the treated cells are injected back into the patient.

Two employees of Therakos alleged back in 2012 that the company used certain tactics to persuade doctors into prescribing the CELLEX and UVAR XTS systems as unapproved treatments for GvHD, or graft-versus host-disease, for children and adults. However, the FDA hadn't approved the systems for use in pediatric patients.

Following the employees' allegations, the U.S. Department of Justice initiated investigations into both Gores and MDBS.

The investigation led to allegations that the two companies marketed the Therakos ECP systems improperly, in a way the FDA didn't approve. Because of this, they also submitted false claims to Tricare, Medicaid, and the Federal Employee Health Benefits Program.

The two companies negotiated the settlements with the California Department of Justice's Division of Medi-Cal Fraud and Elder Abuse. They also worked with the federal government and teams from other states around the country.

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Tags: Business Continuity, Marketing

Tennessee Man Will Spend 3 Years in Prison for Role in Federal Health-Care Fraud
Thinkers360
June 30, 2021

A 59-year-old Tennessee man was sentenced to three years in federal prison recently for his role in a federal health-care fraud scheme.

Michael Dube, the former owner and operator of American Toxicology Labs, received his sentence in Virginia U.S. District Court. He had pleaded guilty to two separate felony charges of health-care fraud. One charge was in the Kentucky’s Eastern District while the other was in Virginia’s Western District.

Court documents said that in March of 211, Dube had pleaded guilty to a charge omitting information intentionally from reports that are required by the Controlled Substances Act. That charge was filed in Tennessee’s Eastern District.

Because of the conviction in that case, Dube couldn’t participate in any federal health-care program. The Department of Health and Human services informed him of this restriction in a letter they sent him in June of 2012.

Even still, Dube and his wife Regan opened American Toxicology Labs in Tennessee in May of 2013. Regan served as the registered agent for the company, and the couple used their home address for the mailing address and principal office.

After establishing the practice, the couple completed applications to participate in Medicaid and Medicare. Those applications listed Regan Dube as the owner of the company, while Michael’s name, and participation in the company, was completely omitted from the application.

American Toxicology Labs conducted urine screenings for multiple entities that said they were opioid treatment facilities. Payments totaling roughly $8.5 million were made to the company between May of 2014 and January of 2020 from Virginia Medicaid, TennCare, Kentucky Medicaid and Medicare.

In this timeframe, Michael negotiated with providers, made decisions regarding employment and participated in the general management of the company.

In addition, Michael received kickbacks from companies for referring patients to those other companies for various services. Payment for those services was given by federal health-care programs, either in full or in part.

A total of $441,646 in these kickbacks was deposited into the personal checking account of the Dubes. Regan had been previously convicted and then sentenced for her role in the scheme.

As a result of the two convictions, the Dubes will pay more than $9 million plus interest. It will divided among fines, forfeiture, restitution and special assessments. All money the couple received from Medicaid and Medicare will have to be re-paid.

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Tags: Health and Safety, Health and Wellness, Healthtech

Two Kentucky Doctors Charged with Multiple Counts of Health-Care Fraud, Distributing Opioids Illegally
Thinkers360
June 16, 2021

Two doctors from a pain clinic in Kentucky have been charged for their roles in a conspiracy to distribute opioids illegally. The doctors will also face charges of conspiracy to commit health-care fraud, after a Kentucky federal grand jury approved an indictment recently.

The conspiracy perpetrated by the doctors allegedly led to the overdose deaths of at least six people. The doctors at the root of the investigation are William Lawrence Siefert, a 67-year-old from Dayton, Ohio, as well as Timothy Ehn, a 48-year-old from Union, Kentucky.

Court documents say the two orchestrated their scheme through the Northern Kentucky Center for Pain Relief, which is a clinic for pain located in Florence, Kentucky.

At the time of alleged conspiracies to commit health-care fraud and prescribe opioids illegally, Siefert was working as a medical doctor for the clinic. Ehn was a chiropractor and owned the pain clinic.

Together, the pair is alleged to have offered patients who were seeking drugs access to opioids that they shouldn’t have been given. The doctors billed Medicaid for urinalysis testing for these patients that was deemed medically unnecessary.

The Kentucky indictment charges each of the doctors with one count of conspiracy to unlawfully distribute a controlled dangerous substance as well as one count of conspiracy to commit health-care fraud.

Siefert will also face separate charges for the incident. That includes 11 counts of illegal distribution of the controlled substances including clonazepam, hydrocodone and oxycodone, as well as three counts of health-care fraud.

Ehn also separately faces eight counts of health-care fraud.

The case was investigated by a joint task force including local offices from the DEA, FBI, HHS-OIG and Kentucky’s MFCU.

All defendants in cases are presumed innocent until they are proven guilty in a court of law beyond a reasonable doubt. Indictments are just allegations of crimes.

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Tags: Health and Wellness, Healthtech

Medical Tech Company Agrees to Multi-Million-Dollar Settlement after Self-Reporting Fraud
Thinkers360
June 11, 2021

As part of a recent settlement agreement, Bioventus LLC will pay more than $3.6 million to the government. The global medical technology company was accused of violating the False Claims Act. According to the U.S. Attorney’s North Carolina office, Bioventus was accused of submitted CMNs, or certificates of medical necessity, that were completed improperly for devices that weren’t medically necessary. The alleged incidents took place between October 1, 2012, and December 31, 2018.

Officials from Bioventus self-disclosed the incidents to the Office of Inspector General at the U.S. Department of Health and Human Services. The case was eventually transferred over to the Middle District of North Carolina office of the U.S. Attorney’s office.

The self-disclosure happened in November 2018. Company officials disclosed they discovered that some of its sales representatives would sometimes complete Section B of a CMN for devices the company produced called Exogen. However, law stipulates that Section B has to be completed by either a physician’s office or a treating physician.

The company then conduct a review of the supposed claims, verifying medical records that would support the claim of medical necessity for the devices.

Government officials said Bioventus cooperated fully with the investigation following their self-disclosure.

The special agent in charge for the Department of Health and Human Services, Derrick Jackson, commented:

“Medicare rules on medical necessity are enforced to protect patients and the integrity of this federal health care program. We encourage providers to voluntarily disclose evidence of potential fraud, as in this case, to resolve these matters.”

HHS-OIG provides a way for enrollees of Medicare to self-disclose any evidence they find of possible fraud. It even has a portal and framework that describes how to disclose, coordinate, evaluate and resolve suspected fraud instances involving any health-care program at the federal level.

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Tags: Healthtech

Managers at Arch Family Dentistry in Indiana Charged with Healthcare Fraud
Thinkers360
May 26, 2021

Two managers of an Indiana family dentistry practice have been charged with one count of healthcare fraud. According to an unsealed indictment from a Grand Jury, 34-year-old Justyn Arch and 31-year-old Trystan Arch, who are from Valparaiso, are facing the charge in the case.

Court documents say the two defendants created a scheme designed to defraud the Indiana Medicaid program. The two created fictitious and false entries in various patient files. The entries showed that dentists at their practice, Arch Complete Family Dentistry, performed patient dental surgery.

That supposed surgery never happened, though. In total, the scheme resulted in false claims in excess of $350,000 being charged to the Indiana Medicaid program.

As of October in 2017, Justyn Arch was managing the practice’s office in Crown Point. He also serves as vice president for the practice. At that time, Trystan Arch served as the manager of the practice’s office in Chesterton.

The practice also briefly had an office in Knox.

The indictment is an allegation of a crime taking place, according to the U.S. Attorney’s Office. All people are presumed to be innocent unless they are found guilty in a court of law.

If the defendants were found guilty, the judge in the case would impose the sentence. The judge would consider guidelines outlined in the federal sentencing program as well as various federal statutes to make his or her determination.

Philip C. Benson, an assistant U.S. Attorney, is prosecuting this case.

The investigation was a joint effort conducted by local and federal authorities, including the FBI and the IRS.

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Tags: Healthtech

One of the Most Chronic Conditions Today Is the Major Depressive Disorder (MDD)
Thinkers360
April 29, 2021

According to Buzi, Smith, and Weinman (2014), one of the most chronic conditions today is the major depressive disorder (MDD). As per the U.S department of health and human services, 8% of the U.S. population aged between 12 to 17 years had at least one MDD episode in 2010. The researchers also found out the rate of mental illness among individuals who are 18-25 years was twice as high in comparison to the rate of mental illness among elderly individuals aged 50 years and above.

Additionally, males were found to experience more persistent depressive symptoms from adolescence into adulthood than females, with Non-Hispanic African American males having the highest rates of MDD at 13.2%, followed by Hispanics or Latinos (12.7%) and lastlynon-Hispanic whites (8.7%). However, despite the fact that males suffer from depression, just like females, very few male individuals seek mental help because of the pressure conceal weaknesses as well as their vulnerabilities.

A place where males have an opportunity to seek mental help is a family planning clinic that provides access to reproductive health services to males. However, because research on males' mental health needs in these settings is scant, Buzi, Smith, and Weinman (2014), used this setting to assess depression among 535 Hispanic and African American males aged between 14 and 27.

Hypothesis

An association exists between depression in males and socio-demographics as well as between depression in males and services they request that are related to relationships, their feelings, physical issues as well as well-being.

Methods

Firstly, the research study included 535 participants who were mainly African American and Hispanic Young males who attended a family planning clinic. Participants were recruited by the researchers during their visit to the clinic on male designated days. The overall sample size reflected 61% of the males who were seen at the clinic during the study period. The researchers obtained informed consent from all the participants before data was collected. Additionally, to protect the confidentiality of participants involved in the research study, every participant had to complete the questionnaire in a private room. Data obtained was analyzed using the chi-square test.

Characteristics of Participants

The researcher used a diverse group of participants in their research. Firstly, as highlighted above, the research study included African Americans (66%) and Hispanic (34%), young males. 92.2 percent of the participants were single, while only 31 percent were fathers. 46.6 percent of participants were in school, and 67.2 percent had graduated high school or were in college. Lastly, a total of 196 participants were employed, and 124 had health insurance.

Variables Used in the Research Study

The dependent variable in the study is depression. Participant's depression levels were measured using the Center for Epidemiologies Studies Depression Scale (CES-D). This variable was measured on an ordinal level of measurement since participants were asked to rate items such as

Depressed mood, feelings of hopelessness, feelings of worthlessness, loss of appetite, poor concentration, and sleep disturbance, and possible scores ranged from 0 to 60, with higher scores indicating more severe depressive symptoms.

The two independent variables in the research study were, participant’s sociodemographic characteristics such as their ethnicity, school status, age, marital status, employment status as well as fatherhood status as well as service requests from participants that included services to assist with relationships, health screenings, anger management, employment, as well as education. The two independent variables were measured on a nominal scale since they had no quantitative value associated with them. 

Results

Chi-square analyses were used by the researchers to determine if an association existed between depression and sociodemographic characteristics because these variables are categorical variables. The results indicated that Hispanic males were more depressed than African American males. Additionally, depressed males requested services related to STD prevention, getting along with family and partners, getting a job, working out, eating well, testicular cancer, college applications/loans, as well as emergency contraception.

Conclusion

The researchers concluded that an association exists between depression and a person’s race. They also asserted that depression is also associated with the type of services requested by young minority males attending a family planning clinic.

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Tags: Health and Wellness, Healthtech

Elements of Effective Compliance Plans for Healthcare Businesses
Thinkers360
April 22, 2021
In the early beginnings of compliance plans for healthcare businesses, big and small, there was a strong suggestion that all healthcare businesses, practices, hospitals and the like adopt a compliance program but there was no directive as to ensuring that a the plan actually worked or was comprehensive enough to ensure the mitigation of potential issues, False Claims Act matters, kickbacks, and the like. The important part of this in approximately 1998 was to have a plan in place, put it on a shelf and if anyone asked to review it, most practices that did implement a plan would pull it off that shelf, dust it off and provide it to the requester. Times have changed. Healthcare compliance impacts every single health organization, providers and related businesses. Given the federal government’s enhanced efforts to investigate and audit, the compliance program has taken on even greater importance. Failure to comply and demonstrate that the compliance program actually works (the healthcare organizations and providers) must be able to show the plan is in effect, includes all basic elements required, is constantly monitored and adjusted to compensate for constant changes in healthcare. Failure to comply can result in criminal charges, significant penalties, debarment from Medicare/Medicaid and other health plans. A healthy, amoebic compliance program can prevent issues and promote legal compliance, ethical compliance and ensure that the businesses and practices meet their obligations associated with ethical matters. The compliance plan is designed to aid in the reduction and detection of fraud, waste and abuse, pursuant to the HHS/OIG, within the healthcare arena. The OIG is the primary investigator of health care fraud within the Medicare programs. Each Medicaid agency is required to investigate Medicaid fraud and abuse, along with the Medicaid Fraud Control Units that exist in the overwhelming number of states. The MFCU has the ability to prosecute for criminal acts as well as civil violations. The HHS/OIG has the power to bring criminal charges, impose civil charges and assess penalties which range from just over $11,000 to approximately $23,500 per violation. For good measure, the Patient Protection and Affordable Care Act requires “all healthcare organizations to develop and implement formal healthcare compliance programs” while also better definingthe importance of healthcare compliance. The compliance programs and adherence thereto are a continuous effort to abide by ethical, legal, and standards which exist in the healthcare arena. In order to ensure compliance plans are followed, the culture of compliance begins at the top and is mandated from the top through every person in the organization. There is no level within a practice nor an organization which is immune to compliance. This will aid in preventing the significant penalties, civil assessments and even criminal charges. Compliance runs through an organization. There are multitude of items which aid in developing and implementing an effective compliance plan for healthcare organizations. Some of these include: 1. Developing open lines of communication throughout the organization from the CEO to the Chief Compliance Officer and others in compliance, to supervisors, staff, managers, directors and everyone else not listed 2. Implementation of comprehensive written policies to be monitored and followed by all employees 3. Conducting effective and recurring training for all personnel 4. Naming a Chief Compliance Officer and a Deputy Compliance Officer as well as a Compliance Committee to support the goals of the compliance program and ensure proper focus is placed on complying with what the plan mandates 5. Ensure that the compliance plan is written and continually updated with all personnel informed of the continuous changes 6. Conduct recurring audits and investigations to ensure the compliance plan is working correctly 7. Enforce discipline for those who do not follow the plan, and 8) Taking prompt action when violations of the plan are noted (through audit and investigations), recording the violation and take action to immediately correct and put into place those rules which will prevent a repetition in the future. There are many more issues to consider but, since the PPACA mandates this, it is in the best interest of every healthcare organization and practice to take heed, else face the consequences which can be both costly in terms of finance and inability to treat certain patients in the future. White Collar, llc can be your best friend in ensuring that your plan is in compliance, monitor it for failures and audit/investigate issues which demand corrective action. We have a combined 100 plus years experience in this area and can make a difference in your practice and/or organization.

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Tags: Health and Safety, Health and Wellness

Fraud and Abuse in Federal and State Healthcare Programs - Much More Than Money
Thinkers360
April 02, 2021
Current estimates place percentages on healthcare fraud and abuse at between 3% and 10% of every claim submitted, which translates to an approximate value of just over $300 Billion annually. Certainly, this has a crippling economic effect on healthcare programs and delivery systems, obviously affecting operations and opportunities to provide leading-edge care. These numbers are supported by Health and Human Services/Office of the Inspector General (“HHS/OIG”) as well as the National Health Care Anti-Fraud Association (“NHCAA”) and while the exact numbers elude calculation and reporting, the estimates are staggering in and of themselves! Lauren Hersch Nicholas, assistant professor at Johns Hopkins Bloomberg School of Public Health and a widely respected author reports that healthcare fraud and abuse resulted in approximately 7,000 deaths in 2013 alone, all of which were deemed “premature”. This further exemplifiesJohns Hopkins’ statistics which reflect that patients who received healthcare services by providers later excluded/debarred from participating in federal and/or state healthcare programs (for healthcare frauds and/or abuses) were between 14% and 17% more likely to die than those who received healthcare services by providers who followed the rules. The populations who are most affected by federal and state healthcare programs are those enrolled in Medicare (typically those over age 65) and Medicaid (aged, blind, disabled, children, long-term care residents, and others, many of whom are without other means to access healthcare. Federal and state healthcare programs are fraught with bad actors committing fraud and abuse. The fact that these populations are disproportionately targeted provides a logical connection that they are the ones who will suffer most from nefarious actors and their schemes to game the systems. The almost 7,000 documented deaths, discussed by Ms. Hersch Nicholas, are beyond troubling and suggest that efforts by States and the federal government be redoubled to curb fraud and abuse schemes, large and small. Sadly, the connection between improving one’s financial status by taking advantage of those who need the most and often the best care, demonstrates the premise that healthcare fraud and abuse is much more than a simple financial, “no-one-gets-hurt” crime.

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Tags: Health and Safety, Health and Wellness

COVID-19 Fraud: Schemes Being Perpetrated and Their True Costs to the United States
Thinkers360
February 24, 2021
Since the advent of COVID-19, criminals across the globe have been exploiting the virus via a multitude of fraud schemes. This has come to the attention of the FBI and other federal law enforcement agencies, including HHS/OIG. Sadly, this fraud is so rampant that a recent report found that over $175,000,000 has already been scammed out of innocent, trusting people who have fallen for these schemes out of fear, intimidation, news reports, promises of cures, and the overwhelming number of robocalls that make false promises. These schemes have become extremelyconvincing, and include fraudulent promises of antibody tests. In these schemes, callers and advertisers want your personal and health information so that they can bill for false tests and either get paid by the insurance companies or by individuals without health insurance. Examples of Fraud Schemes One example to be aware of is the fact that no antibody test has been approved by the Food and Drug Administration. Any claim to the contrary is false, and a potentially fraudulent way to obtain your health information. Another includes antibody tests that are promoted via social media platforms like Facebook, Instagram, and LinkedIn. These types of promotions may also come through telephone calls, emails, texts and various other online advertisements as well. Those who market COVID-19 tests and promise great free benefits if you provide your health insurance information are purely marketers looking for your personal data, which you should never provide. If anyone who says they are from the federal or state governments contacts you, and mandates that you must take the antibody test, do not listen to them and do not give them any information. These calls are also fraudulent. Finally, any medical practitioner (e.g. doctor, nurse practitioner, nursing assistant, RN, or lab professional) who will only take cash in exchange for the testing is acting in a fraudulent manner. Additional Examples of Fraud At this juncture, there is no cure for COVID-19, despite vaccines having recently been approved by the FDA. Beware of sales calls, emails, online ads, and social media ads promising cures. These claims are false, and all the person on the other end cares about is taking your money. If you receive calls from the IRS or Department of the Treasury Department, always remember that the IRS never calls. They use USPS first. Also, anyone promising stimulus checks is a fraudster. If you are receiving mass mailings about COVID-19, they too are false and only want your personal health information (PHI). Never share this information with anyone other than your healthcare provider. Never give out your Medicaid or Medicare card information either; they will only use it to bill those payors, without a service ever being rendered. Never buy a STEAM, ITUNES, GOOGLE Play, money order, or Money Gram card or send cash to strangers who request it. The overwhelming majority (approximately 99%) of such requests are fraudulent. Never share your banking information with people who call, email, send you direct mail, or sellon social media platforms. Once again, they only want your money. Protect Your Personal Information All these fraudsters want is your personal information, your healthcare information,your healthcare card information and/or any other personal data. The key is to be aware of all of these schemes, and to make sure your information doesn’t fall into the hands of strangers with mal intent. This will ensure that you are not scammed out of significant monies. As a nation, we have to be diligent, aware and on guard to protect ourselves, as well as our money and personal data, including health data. This is a time to be prepared and to listen to what the government publishes; if it comes from anywhere else, beware.

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Tags: COVID19

The 10 Most Common Fraud Schemes That Have Arose from COVID-19
Thinkers360
February 24, 2021
Unfortunately, natural disasters represent a prime time for fraudsters to strike – with their multitude of schemes and scams – and during the period when people are likely most vulnerable. During these times, most people aren’t thinking about fraud. Government agencies aren’t either. Their primary focus is onhelping people, as opposed to stopping fraudsters from fleecing unsuspecting people who are grasping for their belongings, their homes, and their safety. The federal government has projected that COVID-19 fraud has the potential to be the most significant fraud in the United States. This is due to the length of time the pandemic has plagued the country, as well as the non-stop flurry of accurate, inaccurate and politically motivated news about its dangers and the damaging effects it has had on the economy as a whole. People are scared of the virus and want the best to either prevent it, deter it, and/or recover from it should they contract it. This presents fraudsters with the opportunity to act in ways which benefit them – and subject citizens to having their monies taken. The fraud schemes during this COVID-19 environment include, but are certainly not limited to:
  1. Phishing and malware schemes. Malicious software and fraudulent communications meant to gain data, damage devices, and induce people to provide financial data, credentials, and log-in information.
  2. Spoofing schemes. Those which are designed to appear as being generated from legitimate sources but, in fact, are criminal in nature.
  3. Fake COVID-19 apps. These can be used to infiltrate individuals’ information and then demand a “ransom” to be paid in bitcoins, or else all personal information will be released on the Internet.
  4. Product scams. These include products which do nothing to contain, deter, prevent or cure the virus; but are, instead, fake products, unsafe products, damaged goods, or even counterfeit goods (e.g. personal protection equipment, hand sanitizer, masks, latex gloves, cures for the virus).
  5. Medical supply scams. Similar to product scams but include ventilators, masks, gowns, related medical supplies and hospital-associated supplies.
  6. Business email fraud. Fraudsters attempting to gain employee data (e.g. social security numbers, addresses, full names, phone numbers and other identifiable data) which can be sold or used to garner payments and compromise or misdirect transfers of monies.
  7. Investment fraud. The pumping and dumping of penny stocks for companies that have “found the cure” for the coronavirus. With these types of scams, there are promises of great returns on investments in gold, silver, and other precious metals and cryptocurrencies.
  8. Charity scams designed to make people believe they are legitimate, and that the donations will be used for the stated purpose. In reality, they are nothing more than shell companies designed to take your money.
  9. Testing scams designed to report positive tests, as well as sell fake or counterfeit goods,to raise revenue from the billing to insurance companies.
  10. Cures for the virus. These are being sold as fast as people can make them up.The most recent was a cure using Clorox, which was touted and sold on Amazon as the greatest cure ever.

To date, COVID-19 fraud has cost Americans approximately $200,000,000, while over $30B in stimulus funds have been distributed. These numbers are reported by the FTC and the U.S. Secret Service. Unfortunately, there is no end in sight, and projections reflect no meaningful change for at least another 12 months.

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Tags: COVID19

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