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Category Archives: Sample Medical Coding Exam

Richmond Hospitalist Group Settles Federal FCA Case

Fredericksburg Hospitalist Group, located in Richmond, VA, and fourteen of its member shareholders have agreed to pay nearly $ 4.2 million to settle a federal FCA case brought under the “qui tam whistleblower” provisions. Dana J. Boente, U.S. Attorney for the Eastern District of Virgini, said, “Rooting out fraudulent billing by healthcare providers is a priority. This office will continue to pursue such matters vigorously.

 

Read the full article here: https://www.justice.gov/usao-edva/pr/fredericksburg-hospitalist-group-pays-42-million-settle-civil-fraud-case

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Medicare overbilled by $41.9M – Mount Sinai Hospital

New York City: According to a recent OIG report, Mount Sinai Hospital failed to comply with Medicare’s billing requirements for 110 outpatient and inpatient claims reviewed by the office of Inspector General for the audit period of January 1st, 2012, through December 31st, 2013.

Read the Full Story Here!

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Medicare Advantage Organization and Former COO to Pay $32.5 Million to Settle False Claims Act Allegations

Freedom Health Inc., a Tampa, Florida-based provider of managed care services, and its related corporate entities (collectively “Freedom Health”), agreed to pay $ 31,695,593 to resolve allegations that they violated the False Claims Act by engaging in illegal schemes to maximize their payment from the government in connection with their Medicare Advantage plans, the Justice Department announced today. In addition, the former Chief Operating Officer (COO) of Freedom Health Siddhartha Pagidipati, has agreed to pay $ 750,000 to resolve his alleged role in one of these schemes. You can read the full update on the justice.gov website – here.

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$750,000 HIPAA SETTLEMENT CAUSES OCR TO UNDERSCORE NEED FOR ORGANIZATION WIDE RISK ANALYSIS

In a $ 750,000 HIPAA Settlement, the University of Washington Medicine (UWM) has agreed to settle charges that it potentially violated the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Security Rule by failing to implement policies and procedures to prevent, detect, contain, and correct security violations.  UWM is an affiliated covered entity, which includes designated health care components and other entities under the control of the University of Washington, including University of Washington Medical Center, the primary teaching hospital of the University of Washington School of Medicine.  Affiliated covered entities must have in place appropriate policies and processes to assure HIPAA compliance with respect to each of the entities that are part of the affiliated group.  The settlement includes a monetary payment of $ 750,000, a corrective action plan, and annual reports on the organization’s compliance efforts.

You can review the complete notice on the HHS.gov website.

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Effects of ICD-10 on Coding Production – Example from MGMA Community

Now that ICD-10 has been rolled out, medical coding companies are feeling its effects. The Medical Group Management Association (MGMA) and its affiliates are having to recreate their processes in order to account for the vast increase in the number and variety of codes. What was once a simple system with a mere 13,000 codes is now far more complex with 68,000.

Companies like the Coding Network are forerunners in ICD-10 Readiness, already having switched our processes to get away from the soon-to-be defunct ICD-9. Whether it be a simple audit or a complicated coding project, TCN’s production rate has never been higher.

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Calif State Medicaid Fraud Unit Recovers $795 Million in Judgements

California State Medicaid Fraud Control Unit: 2015 Onsite Review (OEI-09-15-00070) http://go.usa.gov/cpgj5
 
Why We Did This Study

OIG oversees all State Medicaid Fraud Control Units (MFCUs or Units). As part of this oversight, OIG conducts periodic reviews of all Units and prepares public reports based on these reviews. The reviews assess Unit performance in accordance with the 12 MFCU performance standards and monitor Unit compliance with Federal grant requirements.

How We Did This Study

We conducted an onsite review of the California Unit in February 2015.

What We Found

During FYs 2012-2014, the Unit expended $ 83 million and generated 337 convictions, 67 civil judgments and settlements, and total recoveries of $ 795 million, $ 531 million of which was attributed to cases investigated directly by the Unit.

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23 felonies for a Salinas medical office manager

An office manager who worked with a Salinas doctor was arrested and arraigned on 23 different felonies. Maria “Aloha” Eclavea faced 23 felony insurance charges which are related to her work with Dr. Steven Mangar. These charged are part of an alleged insurance scheme, the Monterey County District Attorney’s Office says.

You can read the full story here: http://www.thecalifornian.com/story/news/my-safety/2016/06/01/salinas-medical-office-manager-charged-23-felonies/85218144/

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Dermatology Physicians / Practice to Pay $1.9 Million to Settle Overbilling Medicare for E&M Services

Abusers of the Medicare system can sometimes be intentional or not, but the stories that really get significant attention of the public are the ones that highlight healthcare personnel that intentionally over bill Medicare.

There are several types of abuse including falsifying claim forms adjusting the actual cost of services, Billing for services and supplies that were not provided, and even billing for appointments that were canceled.

On April 18, 2016, The U.S. Attorney’s Office for the Northern District of Georgia announced that it has reached a settlement with dermatologists Margaret Kopchick, M.D., and Russell Burken, M.D., and their practice group, Toccoa Cl
inic Medical Associates, who agreed collectively to pay $ 1.9 million to settle claims that they violated the False Claims Act by billing Medicare for evaluation and management (E&M) services that were not permitted by Medicare rules.

“The improper billing of evaluation and management services cost the taxpayers millions of dollars each year and drain the Medicare Trust Fund,” said Derrick L. Jackson, Special Agent in Charge of the U.S. Department of Health and Human Services, Office of Inspector General (HHS-OIG) for the Atlanta region.  “The OIG and the U.S. Attorney’s Office will continue to hold health care providers like these responsible for improper claims.”

You can read the full press release on the justice.gov website here.

For further information please contact the U.S. Attorney’s Public Affairs Office atUSAGAN.PressEmails@usdoj.gov or (404) 581-6016.  The Internet address for the U.S. Attorney’s Office for the Northern District of Georgia is http://www.justice.gov/usao-ndga.

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Medical Billing Codes Key to Fraud Case Against 2 Erie Oral Surgeons

John F. Lehrian, who is retired, and David E. Palo, of what was known as Lehrian & Palo Oral Surgery, 100 State St., pleaded not guilty to federal charges that they the defrauded insurance companies of more than $ 323,000. They were indicted July 12 on charges of health care fraud. The government is alleging Lehrian and Palo charged the insurance companies for pulling teeth using surgical extractions. Those extractions, the government said, were unnecessary and more expensive than what should have been the necessary procedures for removing the teeth.

A grand jury in Erie indicted the two separately. The U.S. attorney’s office is alleging their bills were fraudulent because they never needed to surgically extract many teeth — 26 for Palo and 20 for Lehrian. The government said nine of the teeth Palo said he pulled were baby teeth, and that some of the teeth Lehrian said he pulled were decayed and did not need surgical extraction for removal.

You can read the full article on GoErie.com here.

 

 

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UMC, and the estate of a late doctor, deny fraud allegations and agree to pay $3.3 million settlement

Physicians at UMC, as well as the estate of a Lubbock doctor killed in a plane crash last February, have agreed to pay a $ 3.3 million settlement to the federal and state government against allegations of false Medicaid and Medicare submitted claims.

Read the full story here: http://lubbockonline.com/filed-online/2016-08-08/estate-late-doctor-umc-deny-fraud-allegations-agree-pay-nearly-33-million#

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