Several health care providers, pharmacies, and other entities self-disclosed alleged fraudulent or illegal conduct to the HHS Office of the Inspector General (OIG) in September 2016 under the Provider Self-Disclosure Protocol (SDP). The disclosures resulted in payments to the OIG as high as $3,219,483.45 for alleged violations of the Civil Monetary Penalties Law (42 U.S.C. § 1320a–7a). The disclosed conduct related to: kickbacks, improper recertification, improperly supervised radiation services, the employment of excluded individuals, improper physician documentation, improper drug claim alterations, and double billing.
SDP. Self-disclosure under the SDP gives providers the opportunity to avoid the costs and disruptions associated with a government investigation, as well as civil or administrative litigation. However, providers who self-disclose prohibited conduct remain liable for violations through the imposition of civil monetary penalties (CMPs), assessments, and exclusion. Nevertheless, the OIG strongly encourages self-disclosure of potential fraudulent conduct. The OIG considers good faith disclosure of potential fraud to be evidence of a robust compliance program. Additionally, the OIG SDP states that self-disclosing entities deserve to pay lower damages than would result in a government-initiated investigation.
Re-certification. Stony Brook University Hospital (Stony Brook), agreed to pay $3,219,483.45 after it self-disclosed its failure to timely obtain re-certification statements for inpatient psychiatric services furnished to Medicare Part A beneficiaries with stays longer than 11 days. Stony Brook also allegedly improperly coded daily activities under its New York Medicaid-qualified Continuing Day Treatment Program, resulting in improper Medicare Part B payments.
Kickbacks. Metroplex Adventist Hospital, Inc. agreed to pay $115,279.50 after it self-disclosed illegal kickback remuneration to a physician in the form of: (1) waived late fees for unpaid rent, and (2) office space leasing agreements, which were passed upon improper calculations of the space actually used by the physician. CareGivers America Home Health Services, LLC also agreed to pay $50,000 for alleged violations of provisions related to physician self-referrals and kickbacks.
Excluded individuals. Drug Abuse Comprehensive Coordinating Office, Inc.; Pediatric Plus Home Healthcare Services, LLC; as well as Consulate Health Care and Vero Beach Facility Operations, LLC paid $32,189.76, $68,353.34, and $30,978.42, respectively, for allegedly employing individuals they knew or should have known were excluded from participation in the federal health care programs. Similarly, Joy Family and Sports Chiropractic paid $12,494.27 for submitting claims for chiropractic services provided by an individual not actively licensed in the state.
Billing. Med Solutions, LLC agreed to pay $429,683.40 after self-disclosing that it double billed Medicare Part B for vials of medication. The provider allegedly improperly billed for the same vial more than once when it used partial vials to avoid waste. Costco Wholesale Corporation agreed to pay $340,157.25 after disclosing that a pharmacy manager improperly altered prescription drug claims for Medicare Part D and Medicaid in order to obtain higher reimbursement.
Documentation. Achievement Center, Inc. agreed to pay $16,523.55 after its self-disclosure led to OIG allegations that services rendered by a behavioral health specialist were unsupported by documentation and therefore not reimbursable. Orthopedic Center of Vero Beach, P.A. agreed to pay $46,904.95 after it self-disclosed it billed for services provided by a physician who used previously recorded consultation notes written by other physicians. American Professional Associates, LLC and Atlanta Oncology Associates LLC (collectively APA/AOA), and Vantage Oncology, LLC, Radiation Oncology Services of America, Inc., and ROSA of Georgia, LLC (collectively Vantage) agreed to pay agreed to pay $125,905.45 and $91,172.91, respectively, for alleged false claim submissions for radiation oncology services provided without direct physician supervision.
Companies: Stony Brook University Hospital; Metroplex Adventist Hospital, Inc.; CareGivers America Home Health Services, LLC; Drug Abuse Comprehensive Coordinating Office, Inc.; Consulate Health Care; Vero Beach Facility Operations, LLC; Joy Family and Sports Chiropractic; Med Solutions, LLC; Costco Wholesale Corporation; Achievement Center, Inc.; Orthopedic Center of Vero Beach, P.A.; American Professional Associates, LLC; Atlanta Oncology Associates, LLC; Vantage Oncology, LLC, Radiation Oncology Services of America, Inc., and ROSA of Georgia, LLC
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