Empirical Risk Management
Empirical Risk Management

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Empirical Risk Management

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Kameron Gifford, CPC

772-267-9453

 

Todd Gifford, MBA

772-267-8156

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30.01.2019
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All NEW 2019 Advanced Risk Management Workshops Are you looking for the best education available in risk adjustment, value-based payments and/or CDI?   Good News - You have found it! Join us for a day of risk adjustment, catch up with colleagues over lunch, and get the best tools in the industry for FREE! Do you need CMEs or CEUs? We have that too! All Workshops are approved by the American Medical Association, American Academy of Family Practice and the American Academy of Professional Coders for CMEs and CEUs. Overview: What is changing for risk adjustment in the V23 model? New ICD-10 codes and HCC categories are here. What should your team be doing now to be successful? Review the different risk adjustment models and their impact on medical practice management for 2020 and beyond. CMS has proposed new HCCs for PY 2020. What should you be doing now to prepare? Discuss the impact of shifting from RAPS to EDS. What does this mean for office based claims? Take a deep dive into HCC Coding and Documentation. Review real documentation examples to see what validates, what doesn’t, and why.    Learn how to leverage frontline staff to be successful in the world of risk adjustment and value-based payments.  Download the Agenda Here Who Should Attend? Medical Coders and Billers Providers, Managers and Frontline Staff CDI Specialists Executive Leaders ACO, MSO and IPA Teams Rural Health Centers Health Alliance Members Medicare, Medicaid and Commercial Plans REGISTER BELOW: For Jacksonville on 2/21/2019 For  PBG - SOLD OUT  For Ft. Lauderdale on 4/25/2019 For Orlando on 5/15/2019 HOTELS near UNF in Jacksonville for 2/21/2019 Tru by Hilton Jacksonville St. Johns Town Center, 4640 Tropea Way, Jacksonville, FL 32246-8586 - 1.4 miles from University of North Florida Sheraton Jacksonville Hotel, 10605 Deerwood Park Blvd, Jacksonville, FL 32256-0509 - 2.3 miles from University of North Florida Hilton Garden Inn Jacksonville JTB / Deerwood Park, 9745 Gate Pkwy N, Jacksonville, FL 32246-8221 - 2.6 miles from University of North Florida 1 To SPONSOR an EVENT Please email Kameron Gifford Early Bird Pricing and Group Discounts Register NOW to save $100 with Early Bird Pricing! Bring the WHOLE TEAM to save 10% on your order!
29.01.2019
Empirical Risk
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Prepare for Victory... What will define those who claim victory and those who are defeated in the battle towards value based care? Will it be those organizations with the most money, power and seats at the table? Or will it be those who are nimble, flexible and open to change? I believe it will be both. As victory will not be defined by the owners and head coaches but instead by how the players execute on the field. It will be the game time decisions that matter most. A quarterback who can read the defense and adjust accordingly will provide far greater value to the offense than the most athletic quarterback who misses the blitz every time. Perhaps Napoleon said it best, "Battles are won by the power of the mind." For in a game of inches, the winners and losers will be defined by those who can execute in the moments that matter most. Prepare your team for victory with information at the point of care! ERM Consulting has developed the industries best training for players on the frontline. Approved by AMA, AAFP and AAPC. CMS-HCC Premium Package Prepare your team for success with this deluxe package!  This package includes all of our best sellers - updated for 2019 with Version 23          You will receive: 2019 CMS-HCC Mappings 2019 CMS-HCC Quick Coder 2019 CMS-HCC Essentials (HCC RAF and Trump Chart) 2019 CMS-HCC Coding Cards  Order a set for your entire team!           Visit our online store to see additional products
19.01.2019
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Overview The Centers for Medicare & Medicaid Services (CMS) is announcing a broad array of Medicare Advantage (MA) health plan innovations that will be tested in the Value-Based Insurance Design (VBID) model for CY 2020. The VBID model is being tested under the authority of the CMS Center for Medicare and Medicaid Innovation (Innovation Center). The model is designed to reduce Medicare program expenditures, enhance the quality of care for Medicare beneficiaries, including dual-eligible beneficiaries, and improve the coordination and efficiency of health care service delivery. The changes to the VBID Model announced today aim to contribute to the modernization of Medicare Advantage through increasing choice, lowering cost, and improving the quality of care for Medicare beneficiaries. For CY 2020, and consistent with the requirements of the Bipartisan Budget Act of 2018, eligible Medicare Advantage health plans in all 50 states and territories may apply for the health plan innovations being tested under the VBID model. In addition to currently eligible plan types, Regional Preferred Provider Organizations (RPPO) and all Special Needs Plan (SNP) types – Chronic Condition SNPs (C-SNP), Dual Eligible SNPs (D-SNP), and Institutional SNPs (I-SNP) – are allowed to apply to the VBID Model for 2020. For the CY 2020 VBID application period, which is open now through March 1, 2019, eligible Medicare Advantage organizations may apply to test one or more of the following new interventions: Beginning in CY 2021, the VBID model will also test including the Medicare hospice benefit in Medicare Advantage. CMS will release additional information and guidance on this intervention for interested stakeholders in the coming months through the VBID model website, and through open-door forum type events. Additionally, in order to be able to sufficiently evaluate the impact on cost and quality of these different approaches, CMS is extending the performance period of the VBID model by an additional three years, through 2024. Please refer to the VBID CY 2020 Request for Applications for additional detail on 2020 interventions, as well as how to apply at https://innovation.cms.gov/initiatives/vbid. VBID Model Background Beginning in January 2017, the VBID model began testing the impact of providing eligible Medicare Advantage plans the flexibility to offer reduced cost sharing or additional supplemental benefits to enrollees with select chronic conditions, focusing on the services that are of highest clinical value to them. The model tested whether providing this flexibility could improve health outcomes and reduce expenditures for Medicare Advantage enrollees. In 2017, CMS tested the VBID model in seven states, Arizona, Indiana, Iowa, Massachusetts, Oregon, Pennsylvania, and Tennessee, and allowed testing of VBID interventions for the following disease states: diabetes, congestive heart failure, chronic obstructive pulmonary disease (COPD), past stroke, hypertension, coronary artery disease, mood disorders, and combinations of these categories. In 2018, CMS updated the model to include Alabama, Michigan, and Texas and also allowed for VBID interventions for dementia and rheumatoid arthritis. For 2019, CMS updated the model to include organizations in fifteen additional states, California, Colorado, Florida, Georgia, Hawaii, Maine, Minnesota, Montana, New Jersey, New Mexico, North Carolina, North Dakota, South Dakota, Virginia, and West Virginia to apply and allowed participants to propose a methodology that either 1) identifies enrollees with different chronic conditions than those previously established by CMS or 2) revises the existing approved CMS chronic condition category to focus on a broader or smaller subset of the existing chronic condition. The Bipartisan Budget Act of 2018 required that the model be revised to include all 50 states and territories by 2020.  Consistent with these requirements, eligible Medicare Advantage health plans in all 50 states and territories may apply for the health plan innovations being tested under the VBID model for CY 2020. CY 2017 VBID Evaluation Report The first year VBID model evaluation report provides a description of the VBID model benefit designs and selected conditions as well as early implementation experiences. In the first model year (2017), 9 out of 23 eligible Parent Organizations (POs) within 3 of 7 eligible states chose to participate in the model, targeting COPD, CHF, diabetes, and hypertension. Over 96,000 beneficiaries with specified target conditions were eligible for the VBID model; across all participating POs, 61 percent of eligible beneficiaries actually received VBID benefits.  While most 2017 MA plan data were not complete in time for a full impact analysis for this first report, they will be included in future reports.  Please visit the VBID model website at https://innovation.cms.gov/initiatives/vbid for the CY 2017 VBID Evaluation Report.  VBID Model for CY 2020 and Subsequent Years For CY 2020 and subsequent years, CMS is testing the following health plan innovations in Medicare Advantage through the VBID model. The new interventions described below represent a broad array of value-based approaches to service delivery in MA.  Value-Based Insurance Design by Condition and/or Socioeconomic Status Beginning in CY 2020, participating MA plans may propose offering reduced cost-sharing or additional supplemental benefits, including for “non-primarily health related” items or services, for enrollees based on chronic condition, socioeconomic status determined by qualifying for the low-income subsidy and/or having dual-eligible status, or both. Plans may also propose allowing additional “non-primarily health related” supplemental benefits for all enrollees by disease state, regardless of socioeconomic status. Rewards and Incentives In order to enable more meaningful rewards and incentives that effectively influence healthy behaviors, CMS is testing the impact of permitting broadened Medicare Advantage and Part D Rewards and Incentives (RI) programs. Specifically, plans may propose RI programs with allowed values that more closely reflect the expected benefit of the health related service or activity, up to an annual limit, to better promote improved health, prevent injuries and illness, and promote the efficient use of health care resources. Participating MA plans that offer a Prescription Drug Plan (MA-PDs) may also offer RI programs for enrollees who take covered Part D prescription drugs and who participate in disease state management programs, engage in medication therapy management with pharmacists or providers, receive preventive health services, and actively engage in understanding their medications, including clinically-equivalent alternatives that may be more cost-accessible. Telehealth Networks Through this intervention, CMS is testing how different service delivery innovations in telehealth can be used to both augment and complement an MA plan’s current network of providers, as well as how access to telehealth services may appropriately allow MA plans to expand their service area to currently underserved counties where current MA network adequacy requirements could not be met without the use of telehealth. Where deemed appropriate by CMS, MA plans may propose using telehealth services in lieu of in-person visits to meet network adequacy requirements. Organizations must ensure that enrollee choice is preserved and that enrollee access to an in-person visit, if that is the enrollee’s preference and choice, is maintained. CMS expects that this will provide MA plans with an opportunity to enter into underserved markets, including rural areas where there may be few to no MA plan choices.  The two different approaches CMS is testing are: 1. how plans can use telehealth services to complement and augment their current network of providers, including proposals where telehealth networks may comprise up to one-third of the required in-network providers for a specialty or specialties; and 2. how the use of telehealth services allows MAOs to offer a broadened service area, including counties where the choice of an MA plan may not have previously been able to be offered. Wellness and Health Care Planning Organizations participating in VBID, working with their network of providers, will be required to offer enrollees improved, timely access to Wellness and Health Care Planning (WHP), including advance care planning. Each MA organization applying for the VBID model must submit its proposed approach to WHP for their enrollees as part of the application. Through the VBID model, CMS will evaluate the impact on quality and cost of best practices for performing WHP in the Medicare Advantage population. https://www.cms.gov/newsroom/fact-sheets/value-based-insurance-design-model-vbid-fact-sheet-cy-2020
If so, we can help!  ERM Consulting will work with your team to develop an internal risk adjustment program.  Services Included: Remote Auditing and Monitoring - Review of 25 encounters per provider, per month, with detailed monthly reports to track error trends and validation rates.  Development of Custom Education - Custom education for providers and coders, every quarter, to reinforce positive changes and educate on new opportunities.  Onsite Meetings (One week on-site per Quarter) - 1:1 meetings with providers, coders and leadership to review current audit results and discuss opportunities for improvement.  Oversight and Guidance - ERM will provide oversight and guidance to assist with the development of development of internal team and processes needed to manage new payment models.  Strategic Considerations: Who will be part of the team and what role will they play?  What new processes need to be added or adjusted? How will the team communicate and measure success? Who is On-boarding, Training and Managing your Coders? ERM also offers remote on-boarding, training and management of coders and billing teams.  Visit ERM online or email for more information. Contract during the month of December and receive a 25% Discount – on all HCC Coding Tools by ERM – visit our online store at https://erm.ecwid.com/ to see a complete list.
09.12.2018
Empirical Risk
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Prepare your TEAM for VICTORY in 2019 and Beyond... What will define those who claim victory and those who are defeated in the battle towards value based care? Will it be those organizations with the most money, power and seats at the table? Or will it be those who are nimble, flexible and open to change? I believe it will be both. As victory will not be defined by the owners and head coaches but instead by how the players execute on the field. It will be the game time decisions that matter most. A quarterback who can read the defense and adjust accordingly will provide far greater value to the offense than the most athletic quarterback who misses the blitz every time. Perhaps Napoleon said it best, "Battles are won by the power of the mind." For in a game of inches, the winners and losers will be defined by those who can execute in the moments that matter most. Prepare your team for victory with information at the point of care! ERM Consulting has developed the industries best tools for players on the frontline.  All education is approved for CME / CEU by AMA, AAFP and AAPC. Visit our online store or contact ERM to schedule onsite CME / CEU today.
24.11.2018
Empirical Risk
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Are you looking for the best education available in risk adjustment, value-based payments and/or CDI?   Good News - You have found it! Join us for a day of risk adjustment, catch up with colleagues over lunch, and get the best tools in the industry for FREE! Do you need CMEs or CEUs? We have that too! All Workshops are approved by the American Medical Association, American Academy of Family Practice and the American Academy of Professional Coders.  Overview: What is changing for risk adjustment in 2019? New ICD-10 codes and HCC categories are coming. What should your team be doing now to prepare? Review the different risk adjustment models and their impact on medical practice management for 2019 and beyond.  Discuss the impact of shifting from RAPS to EDS. What does this mean for office based claims? Take a deep dive into HCC Coding and Documentation. Review real documentation examples to see what validates, what doesn’t, and why.   Learn how to leverage frontline staff to be successful in the world of risk adjustment and value-based payments.  Download the Agenda Here Who Should Attend? Medical Coders and Billers Providers, Managers and Frontline Staff CDI Specialists Executive Leaders ACO, MSO and IPA Teams Rural Health Centers Health Alliance Members Medicare, Medicaid and Commercial Plans REGISTER BELOW: For Jacksonville on 2/21/2019 For Palm Beach Gardens on 3/29/2019 For Ft. Lauderdale on 4/25/2019 For Orlando on 5/15/2019 To SPONSOR an EVENT Please email Kameron Gifford Early Bird Pricing and Group Discounts Register NOW to save $100 with Early Bird Pricing! Bring the WHOLE TEAM to save 10% on your order!
03.10.2018
Empirical Risk
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Are you looking for the best education available in risk adjustment? Good News - You have found it! Join us for a day of risk adjustment, catch up with colleagues over lunch, and get the best tools in the industry for FREE! Do you need CMEs or CEUs? We have that too! All Workshops are approved by the American Medical Association, American Academy of Family Practice and the American Academy of Professional Coders. Register your team ( 3 or more) today to save 10% on Tampa and Ft. Lauderdale. Take advantage of Early Bird pricing and Save $100! Improve the Accuracy of your Risk Scores... Overview: What is changing for risk adjustment in 2019? New ICD-10 codes and HCC categories are coming. What should your team be doing now to prepare? Review the different risk adjustment models and their impact on medical practice management for 2019 and beyond. Discuss the impact of shifting from RAPS to EDS. What does this mean for office based claims? Take a deep dive into HCC Coding and Documentation. Review real documentation examples to see what validates, what doesn’t, and why.  Learn how to leverage frontline staff to be successful in the world of risk adjustment and value-based payments. Download the Agenda Here Who Should Attend? Medical Coders and Billers Providers, Managers and Frontline Staff CDI Specialists Executive Leaders ACO, MSO and IPA Teams Rural Health Centers Health Alliance Members Medicare, Medicaid and Commercial Plans REGISTER BELOW: Tampa,Florida HILTON GARDEN INN TAMPA RIVERVIEW 4328 Garden Vista Drive, Riverview, FL 34747 Wednesday - October 24, 2018 10:00 AM - 4:00 PM Early Bird Pricing $100 Register Here Fort Lauderdale, Florida CYPRESS CREEK EXECUTIVE CENTER 1451 W. Cypress Creek Road, Fort Lauderdale, FL, 33309 Thursday November 8, 2018 9:20 AM - 3:30 PM Early Bird Pricing $100 Register Here Visit www.ermconsultinginc.com for more details
29.08.2018
Empirical Risk
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Is your organization currently taking on risk or participating in value-based payment models?  If so, we can help!  ERM Consulting will work with your team to develop an internal risk adjustment program.  Services Included: Remote Auditing and Monitoring - Review of 25 encounters per provider, per month, with detailed monthly reports to track error trends and validation rates.  Development of Custom Education - Custom education for providers and coders, every quarter, to reinforce positive changes and educate on new opportunities.  Onsite Meetings (One week on-site per Quarter) - 1:1 meetings with providers, coders and leadership to review current audit results and discuss opportunities for improvement.  Oversight and Guidance - ERM will provide oversight and guidance to assist with the development of development of internal team and processes needed to manage new payment models.  Strategic Considerations: Who will be part of the team and what role will they play?  What new processes need to be added or adjusted? How will the team communicate and measure success? Who is On-boarding, Training and Managing your Coders? ERM also offers remote on-boarding, training and management of coders and billing teams.  Visit ERM online or email for more information. Contract during the month of September and receive a 25% Discount – on all HCC Coding Tools by ERM – visit our online store at https://erm.ecwid.com/ to see a complete list.
17.07.2018
Empirical Risk
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Evaluation and management (E/M) coding and documentation burden could lighten in 2019 under CMS proposed rule The rule also proposes a single payment rate for level 2 through level 5 office visits. The July/August issue of FPM addressed strategies for distinguishing between 99213 and 99214 office visit codes. That distinction may soon become easier to document but essentially irrelevant to payment. On July 12, the Centers for Medicare & Medicaid Services (CMS) released its proposed changes to the Medicare Physician Fee Schedule for 2019(www.federalregister.gov). The proposed rule contains, among other updates, significant revisions to the coding and documentation of office visit evaluation and management (E/M) services (see page 331 of the proposed rule(s3.amazonaws.com)). While Medicare is only proposing changes to the Office and Other Outpatient Services category of codes (99201-99215) for 2019, Medicare indicates it intends to use a stepwise approach and expand its finalized policy to other E/M code categories (see pages 331-332 of the proposed rule). The changes follow years of auditing from Medicare contractors and widespread concerns from the medical community that existing E/M documentation guidelines no longer reflect current practices and result in unnecessarily burdensome documentation requirements. New time reporting option In selecting a level of service for office or other outpatient services, beginning Jan. 1, 2019, physicians would have increased options available. In addition to using the current 1995 and 1997 documentation guidelines, physicians could select the level of service based on time or by using medical decision-making alone, regardless of the level of history or physical exam performed (see page 335 of the proposed rule). The option to select a level of service based on the duration of the visit relaxes existing requirements. Currently, selecting a visit based on time requires documentation of the duration of face-to-face time with the patient and greater than 50 percent of the visit must be spent in counseling or coordination of care. Medicare’s proposal would eliminate this second requirement, simply allowing physicians to select a code based on the total length of the visit even if counseling did not dominate the service time. (see page 338 of the proposed rule). Medical decision making as the driving factor Especially for new patient visits, which currently require meeting requirements for all three key components of history, examination, and medical decision-making, satisfying requirements for higher levels of service can be difficult. Physicians have long complained that the points system for history and examination components result in unnecessary documentation that does not contribute to patient care. As a result, Medicare proposes to allow physicians to select their level of service for both new and established patient office visits using only the medical decision-making component. The requirements for medical decision making would remain the same. Reducing unnecessary requirements Recognizing several common E/M documentation guideline complaints, Medicare proposes to no longer require physicians to re-record information regarding the chief complaint and history of present illness previously documented by ancillary staff (see pages 343-345 of the proposed rule). Single payment rate The method of supporting your level of service, in some respects, may be a distinction without a difference under the proposed rule. Level 2 through level 5 new and established office visits, respectively, would have a single payment rate regardless of the code reported (see page 349 of the proposed rule). New patients (99202-99205) would be paid at approximately the midpoint between a 99203 and 99204 (see page 349 of the proposed rule), assigning 1.9 work RVUs to new patient visit codes. (Compare that to the 2018 rates for 99203 at 1.42 work RVUs and 99204 at 2.43 work RVUs, with a midpoint of 1.925.) Established patient visits (99212-99215) would be paid just under the midpoint between 99213 and 99214 (see page 349 of the proposed rule), assigning 1.22 work RVUs to established patient visit codes. (Compare that to 2018 rates for 99213 at 0.97 work RVUs and 99214 at 1.5 work RVUs, with a midpoint of 1.235.) The following tables from the proposed rule illustrate the potential financial impact using 2018 work RVU and conversion factor values. Primary care payment bump Visits with a focus on primary care can receive a bump in payment by reporting a new add-on code (specific code to be determined), with a proposed work RVU of 0.07. Impact to physicians Physicians should note that these modifications, if finalized, would only apply to office visit codes and only for Medicare. As a result, the existing 1995 and 1997 E/M guidelines will continue to apply for other services such as hospital visits, and for commercial payers. Note: The release is scheduled for official publication in the Federal Register July 27, 2018. Page references are subject to change upon publication of the Proposed Rule in the Federal Register. – Richelle Marting, JD, an attorney practicing with Forbes Law Group in Overland Park, Kan., where she focuses on regulatory compliance and health care reimbursement https://www.aafp.org/journals/fpm/blogs/gettingpaid/entry/em_coding_proposed_changes.html
National Health Care Fraud Takedown Results in Charges Against 601 Individuals Responsible for Over $2 Billion in Fraud Losses Largest Health Care Fraud Enforcement Action in Department of Justice History Resulted in 76 Doctors Charged and 84 Opioid Cases Involving More Than 13 Million Illegal Dosages of Opioids Attorney General Jeff Sessions and Department of Health and Human Services (HHS) Secretary Alex M. Azar III, announced today the largest ever health care fraud enforcement action involving 601 charged defendants across 58 federal districts, including 165 doctors, nurses and other licensed medical professionals, for their alleged participation in health care fraud schemes involving more than $2 billion in false billings.  Of those charged, 162 defendants, including 76 doctors, were charged for their roles in prescribing and distributing opioids and other dangerous narcotics.  Thirty state Medicaid Fraud Control Units also participated in today’s arrests.  In addition, HHS announced today that from July 2017 to the present, it has excluded 2,700 individuals from participation in Medicare, Medicaid, and all other Federal health care programs, which includes 587 providers excluded for conduct related to opioid diversion and abuse.  Attorney General Sessions and Secretary Azar were joined in the announcement by Acting Assistant Attorney General John P. Cronan of the Justice Department’s Criminal Division, Deputy Director David L. Bowdich of the FBI, Assistant Administrator John Martin of the Drug Enforcement Administration (DEA), Deputy Inspector General Gary Cantrell of the HHS Office of Inspector General (OIG), Deputy Chief Eric Hylton of IRS Criminal Investigation (CI), Centers for Medicare and Medicaid Services (CMS) Deputy Administrator and Director of the Center for Program Integrity Alec Alexander and Director Dermot F. O’Reilly of the Defense Criminal Investigative Service (DCIS). Today’s enforcement actions were led and coordinated by the Criminal Division, Fraud Section’s Health Care Fraud Unit in conjunction with its Medicare Fraud Strike Force (MFSF) partners, a partnership between the Criminal Division, U.S. Attorney’s Offices, the FBI and HHS-OIG.  In addition, the operation includes the participation of the DEA, DCIS, IRS-CI, Department of Labor, other various federal law enforcement agencies, and State Medicaid Fraud Control Units.   The charges announced today aggressively target schemes billing Medicare, Medicaid, TRICARE (a health insurance program for members and veterans of the armed forces and their families), and private insurance companies for medically unnecessary prescription drugs and compounded medications that often were never even purchased and/or distributed to beneficiaries.  The charges also involve individuals contributing to the opioid epidemic, with a particular focus on medical professionals involved in the unlawful distribution of opioids and other prescription narcotics, a particular focus for the Department.  According to the CDC, approximately 115 Americans die every day of an opioid-related overdose.    “Health care fraud is a betrayal of vulnerable patients, and often it is theft from the taxpayer,” said Attorney General Sessions.  “In many cases, doctors, nurses, and pharmacists take advantage of people suffering from drug addiction in order to line their pockets. These are despicable crimes. That’s why this Department of Justice has taken historic new steps to go after fraudsters, including hiring more prosecutors and leveraging the power of data analytics. Today the Department of Justice is announcing the largest health care fraud enforcement action in American history.  This is the most fraud, the most defendants, and the most doctors ever charged in a single operation—and we have evidence that our ongoing work has stopped or prevented billions of dollars’ worth of fraud. I want to thank our fabulous partners with the FBI, DEA, our Health Care Fraud task forces, HHS, the Defense Criminal Investigative Service, IRS Criminal Investigation, Medicare, and especially the more than 1,000 federal, state, local, and tribal law enforcement officers from across America who made this possible. By every measure we are more effective at finding and prosecuting medical fraud than ever.” “Every dollar recovered in this year’s operation represents not just a taxpayer’s hard-earned money—it’s a dollar that can go toward providing healthcare for Americans in need,” said HHS Secretary Azar.  “This year’s Takedown Day is a significant accomplishment for the American people, and every public servant involved should be proud of their work.” According to court documents, the defendants allegedly participated in schemes to submit claims to Medicare, Medicaid, TRICARE, and private insurance companies for treatments that were medically unnecessary and often never provided.  In many cases, patient recruiters, beneficiaries and other co-conspirators were allegedly paid cash kickbacks in return for supplying beneficiary information to providers, so that the providers could then submit fraudulent bills to Medicare.  Collectively, the doctors, nurses, licensed medical professionals, health care company owners and others charged are accused of submitting a total of over $2 billion in fraudulent billings.  The number of medical professionals charged is particularly significant, because virtually every health care fraud scheme requires a corrupt medical professional to be involved in order for Medicare or Medicaid to pay the fraudulent claims.  Aggressively pursuing corrupt medical professionals not only has a deterrent effect on other medical professionals, but also ensures that their licenses can no longer be used to bilk the system. “Healthcare fraud touches every corner of the United States and not only costs taxpayers money, but also can have deadly consequences,” said FBI Deputy Director Bowdich.  “Through investigations across the country, we have seen medical professionals putting greed above their patients’ well-being and trusted doctors fanning the flames of the opioid crisis.  I want to thank the agents, analysts and our law enforcement partners in every field office who work each and every day to stop these criminals and hold them accountable for their actions.” “DEA is committed to ending the opioid crisis occurring in our communities and preventing prescription drug misuse,” said DEA Assistant Administrator Martin.  “DEA will continue to work with our partners every day to protect our citizens while ensuring that patients have adequate access to these critical medications.” “This year’s operations, focusing on opioid-related schemes, spotlight the far-reaching impact of health care fraud,” said HHS Deputy Inspector General Cantrell.  “Such crimes threaten the vitally important Medicare and Medicaid programs and the beneficiaries they serve.  Though we have made significant progress in our fight against health care fraud; our efforts are not complete.  We will continue to work with our partners to protect the health and safety of millions of Americans.” “It takes a special kind of person to prey on the sick and vulnerable as happened in many of these health care fraud schemes,” said Deputy Chief Hylton.  “Medical professionals and others callously placed individuals and vital healthcare services in harm’s way simply because of greed.  IRS-CI special agents continue to work side-by-side with other federal, state and local law enforcement officers to uncover these schemes and hold these criminals accountable for their actions.” “CMS makes it a top priority to protect the health and safety of millions of beneficiaries who depend on vital federal healthcare programs,” said Alec Alexander, deputy administrator and director of the Center for Program Integrity.  “CMS’ Center for Program Integrity collaborates closely with our law enforcement partners to safeguard precious taxpayer dollars. Under Administrator Seema Verma, we will continue to strengthen this partnership with law enforcement in order to ensure the integrity and sustainability of these essential programs that serve millions of Americans.” “Heath care fraud wounds our service members and veterans alike, as they rely upon and rightfully expect uncompromised care through the Department of Defense’s TRICARE Program,” said DCIS Director O’Reilly.  “Investigations that culminated in enforcement actions over the past several days underscore the steadfast commitment of the Defense Criminal Investigative Service and our investigative partners to vigorously investigate fraud impacting TRICARE.  We remain vigilant in our efforts to ensure the high standards of care our service members, military retirees, and their dependents deserve while safeguarding American taxpayer dollars.”  The Medicare Fraud Strike Force operations are part of a joint initiative between the Department of Justice and HHS to focus their efforts to prevent and deter fraud and enforce current anti-fraud laws around the country.  The Medicare Fraud Strike Force operates in 10 locations nationwide.  Since its inception in March 2007, the Medicare Fraud Strike Force has charged over 3,700 defendants who collectively have falsely billed the Medicare program for over $14 billion. ********* For the Strike Force locations, in the Southern District of Florida, 124 defendants were charged with offenses relating to their participation in various fraud schemes involving over $337 million in false billings for services including home health care and pharmacy fraud.  In one case, an owner, medical director, and two employees of a sober living facility were charged with conspiracy to commit health care and wire fraud, substantive counts of health care fraud, and substantive counts of money laundering.  The indictment alleges a scheme that illegally recruited patients, paid kickbacks, and defrauded health care benefit programs for widespread fraudulent urine testing.  During the course of the fraudulent scheme, the facility submitted more than $106 million in claims for substance abuse treatment services.  In the Central District of California, 33 defendants were charged for their roles in schemes to defraud insurance programs out of more than $660 million.  For example, one indictment in a compounding pharmacy fraud case alleges an attorney/marketer paid kickbacks and offered incentives such as prostitutes and expensive meals to two podiatrists in exchange for prescriptions written on pre-printed prescription pads, regardless of the medical need for the prescriptions.  Once the prescriptions were filled, members of the conspiracy submitted approximately $250 million in fraudulent claims to federal, state, and private insurers for the compounded drugs.  In the Southern District of Texas, 48 individuals were charged in cases involving more than $291 million in alleged fraud.  Among these defendants are a pharmacy chain owner, managing partner, and lead pharmacist charged with a drug and money laundering conspiracy. According to the indictment, the coconspirators used fraudulent prescriptions to fill bulk orders for over one million pills of hydrocodone and oxycodone, which the pharmacy, in turn, sold to drug couriers for millions of dollars.  In the Northern District of Texas, a home health agency owner was arrested on a criminal complaint for a $2.6 million health care fraud scheme. In the Eastern District of Michigan, 35 defendants face charges for their alleged roles in fraud, kickback, money laundering and drug diversion schemes involving approximately $197 million in false claims for services that were medically unnecessary or never rendered.  In one case, a physician was charged in separate kickback conspiracies with two home health agency owners, which resulted in more than $12 million in fraudulent insurance billings. In the Northern District of Illinois, 21 individuals were charged for various fraud schemes involving home health and dental services.  These schemes involved allegedly over $54 million in fraudulent billing.  One case alleges a home health fraud and kickback conspiracy, which resulted in more than $6.2 million paid by Medicare based on the fraudulent billings. In the Eastern District of New York, 13 individuals were charged with participating in a variety of schemes including kickbacks, services not rendered, identity theft and money laundering involving over $38 million in fraudulent billings.  For example, the owner of a Brooklyn ambulette company was charged in a $7 million conspiracy stemming from the alleged payment of kickbacks for the referral of patients, who subjected themselves to purported physical and occupational therapy and other services, and were transported by the ambulette company. In the Middle District of Florida, 21 individuals were charged with participating in a variety of schemes involving more than $21 million in fraudulent billings.  In one case, a physician and clinic owner were charged with a conspiracy to defraud Medicare of more than $2.8 million for fraudulent home health billings. In the Southern Louisiana Strike Force, operating in the Middle and Eastern Districts of Louisiana as well as the Southern District of Mississippi, 42 defendants were charged in connection with health care fraud, drug diversion, and money laundering schemes involving more than $16 million in fraudulent billings.  One case alleges that three pharmacy owners and a nurse practitioner conspired to unlawfully dispense controlled substances and defraud TRICARE and private insurance companies out of $12 million. In the Corporate Strike Force, five defendants were charged in the Middle District of Tennessee with a kickback conspiracy at a durable medical equipment company, which allegedly resulted in more than $1 million in kickbacks and over $2.5 million in fraudulent billings to Medicare.  ********* In addition to the Strike Force locations, today’s enforcement actions include cases and investigations brought by an additional 46 U.S. Attorney’s Offices, including the execution of  search warrants in various investigations conducted by the Central and Northern Districts of California, Middle District of Florida, Southern District of Georgia, Western District of Kentucky, Eastern District of Michigan, Western District of North Carolina, Eastern and Western Districts of Texas, Eastern and Western Districts of Virginia, and Western District of Washington. In the Northern and Southern Districts of Alabama, 15 defendants were charged for their roles in eight health care fraud schemes involving compounding pharmacy fraud and unlawful distribution of controlled substances. In the Eastern District of California, four defendants were charged for their roles in two health care fraud schemes, one of which included forged prescriptions. In the Southern District of California, seven defendants, including a physician, were charged for their roles in three health care fraud schemes and one scheme involving identity theft and services that were not rendered.  In the District of Colorado, a defendant was charged with health care fraud related to billings to Medicaid and Medicare. In the District of Connecticut, three defendants, including two medical professionals, were charged for their roles in two schemes involving compounding drugs and unlawful distribution of Schedule II and IV controlled substances.  In the District of Delaware, a physician/owner of a pain management clinic was charged with unlawfully prescribing more than two million dosage units of Oxycodone products. In the District of Columbia, a durable medical equipment company owner was charged with defrauding Medicaid of $9.8 million. In the Northern District of Florida, four defendants were charged in a scheme to defraud TRICARE and other private insurance companies out of over $8 million for medically unnecessary compounded creams and pills.  In the Northern, Middle, and Southern Districts of Georgia, 12 defendants, including two physicians, were charged in nine health care fraud, drug diversion, or compounding pharmacy schemes involving over $13.5 million in fraudulent billings.  In the District of Idaho, three defendants, all of who are medical professionals, were charged for their roles in three separate fraud schemes involving controlled substances. In the Central and Southern Districts of Illinois, seven defendants were charged in six separate schemes to defraud the Medicaid program. In the Northern District of Indiana, eight defendants were charged in various health care fraud schemes to defraud both the Medicare and Medicaid programs.  In the Northern District of Iowa, two defendants – both medical professionals – were charged for their roles in two opioid-related schemes. In the Districts of Kansas and the Northern and Western Districts of Oklahoma, 12 defendants, including four physicians, were charged in various unlawful distribution of controlled substances schemes.  In the Western District of Oklahoma, one case marks the district’s first time charging unlawful distribution of controlled substances resulting in a death. In the Eastern and Western Districts of Kentucky, 12 defendants, including five medical professionals, were charged in various schemes involving health care fraud, unlawful distribution of controlled substances, aggravated identity theft, and money laundering.  One case involved the operation of two false-front medical clinics. In the Districts of Maine and Vermont, two defendants were charged for their roles in two schemes to defraud various government programs including Medicare, Medicaid, and ones run by the HHS’ Administration for Children and Families. In the District of Nebraska, seven defendants, including one physician, were charged in five separate schemes to defraud Medicare, Medicaid, and various HHS programs. In the District of Nevada, four defendants, including three medical professionals were charged with conspiracies to commit health care fraud and distribute controlled substances.  In the District of New Jersey, eight defendants, including a New York doctor, an anesthesiology technologist for a Philadelphia hospital, and the owner of a medical billing company, were charged for their roles in five schemes to defraud private insurance companies of over $16 million.  In the Southern District of New York, two defendants were charged in schemes involving health care fraud or drug diversion. In the Middle District of North Carolina, two defendants were charged with a conspiracy to defraud Medicare out of over $4 million. In the Southern District of Ohio, three defendants – all medical professionals – were charged for their roles in two health care fraud schemes, one of which involved illegal drug distribution and kickbacks. In the Eastern and Middle Districts of Pennsylvania, 12 defendants were charged for their roles in three drug diversion schemes. In the Western District of Pennsylvania, four defendants – all physicians – were charged in various health care fraud and drug diversion schemes. One scheme involved 32,000 dosage units of buprenorphine. In the District of Rhode Island, one defendant was charged for participating in a theft and aggravated identity theft scheme. In the District of South Carolina, three defendants were charged for their separate roles in a conspiracy to possess with the intent to distribute fentanyl. In the District of South Dakota, two defendants were charged in separate cases, one of which involved a scheme to defraud the Indian Health Service. In the Middle District of Tennessee, 10 defendants were charged in two separate schemes, including a conspiracy to fraudulently obtain oxycodone. In the Eastern District of Texas, two defendants were charged for their role in health care fraud schemes to defraud the Medicare and Medicaid programs. In the District of Utah, two defendants were charged in two cases, one of which involved a $31 million scheme to defraud Medicare and Medicaid. In the Western District of Virginia, eight defendants were charged for their alleged roles in health care fraud schemes.  One $45 million scheme to defraud Medicaid involved falsification of documents in patient files. In the Eastern District of Washington, a dentist and another individual were indicted for distributing and conspiring to distribute hydrocodone and tramadol without a legitimate medical purpose.  In the Eastern District of Wisconsin, three defendants were charged in a scheme involving the unlawful distribution of controlled substances and aggravated identity theft. In addition, in the states of Arizona, Arkansas, California, Connecticut, Delaware, Florida, Hawaii, Illinois, Indiana, Kansas, Louisiana, Maine, Michigan, Missouri, Mississippi, Nevada, New York, Oklahoma, Pennsylvania, Texas, Vermont, and Washington, 97 defendants have been charged with defrauding the Medicaid program out of over $27 million.  These cases were investigated by each state’s respective Medicaid Fraud Control Units.  In addition, the Medicaid Fraud Control Units of the states of California, District of Columbia, Florida, Georgia, Illinois, Indiana, Iowa, Kentucky, Louisiana, Maine, Nevada, North Carolina, Ohio, Texas, Tennessee, and Virginia participated in the investigation of many of the federal cases discussed above.  The cases announced today are being prosecuted and investigated by U.S. Attorney’s Offices nationwide, along with Medicare Fraud Strike Force teams from the Criminal Division’s Fraud Section and from the U.S. Attorney’s Offices in the Southern District of Florida, Eastern District of Michigan, Eastern District of New York, Southern District of Texas, Central District of California, Eastern District of Louisiana, Northern District of Texas, Northern District of Illinois, Middle District of Louisiana, and the Middle District of Florida; and agents from the FBI, HHS-OIG, DEA, DCIS, IRS-CI, Department of Labor, other various federal law enforcement agencies, and state Medicaid Fraud Control Units. A complaint, information, or indictment is merely an allegation, and all defendants are presumed innocent until proven guilty beyond a reasonable doubt in a court of law. Additional documents related to this announcement will shortly be available here:  https://www.justice.gov/opa/pr/national-health-care-fraud-takedown-results-charges-against-601-individuals-responsible-over This operation also highlights the great work being done by the Department of Justice’s Civil Division.  In the past fiscal year, the Department of Justice, including the Civil Division, has collectively won or negotiated over $2 billion in judgements and settlements related to matters alleging health care fraud. 
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