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Office Of The Inspector General - One of the best experts on this subject based on the ideXlab platform.
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Semi-Annual Report to Congress for the Period of October 1, 2016 to March 31, 2017
DigitalCommons@ILR, 2017Co-Authors: Office Of The Inspector GeneralAbstract:[Excerpt] I am pleased to submit to Congress and the Department this Semiannual Report, which highlights the most significant activities and accomplishments of the U.S. Department of Labor (DOL), Office of Inspector General (OIG) for the six-month period ending March 31, 2017. Our audits and investigations continue to assess the effectiveness, efficiency, economy, and integrity of DOL’s programs and operations. We also continue to investigate the influence of labor racketeering and organized crime in internal union affairs, employee benefits plans, and labor-management relations, and have partnered with other law enforcement agencies on human trafficking matters. During this reporting period, the OIG issued 11 audit and other reports that, among other things, identified $26 million in monetary impact. Among our many significant findings, we reported the following: For the period January 1, 2014, to June 30, 2015, 11 of the 12 Job Corps centers reviewed did not contact law enforcement for 42 percent of potentially serious criminal misconduct incidents. At all 12 centers, we identified significant incidents that had not been reported to Job Corps. We also observed physical security weaknesses, such as inoperable closed-circuit television cameras and damaged or no fencing along center perimeters. Finally, Job Corps required pre-employment background checks for only a few center positions. The Mine Safety and Health Administration’s oversight of emergency response plans was insufficient in that all the plans we reviewed contained inaccuracies or omissions, placing miners at unnecessarily increased risk during an emergency. The Occupational Safety and Health Administration did not ensure employers took adequate and timely actions to correct hazards identified during inspections for an estimated 16 percent of the citations the agency issued in FY 2015. The Employee Benefits Security Administration did not have the ability to protect the estimated 79 million plan participants in self-insured Health plans from improper denials of Health claims, due to a lack of knowledge of claim denials in the plans under its oversight. During this reporting period the OIG’s investigative work yielded impressive results, with a total of 45 indictments, 116 convictions, and more than $41 million in monetary accomplishments. Highlights of our work include the following: Executives of a physical therapy company in Texas were convicted of Health Care Fraud, and other charges, for their roles in a scheme to bill DOL’s Office of Workers’ Compensation Programs more than $9.5 million for services that were not provided. The chief executive officer of a Maryland contracting company was sentenced to 68 months in prison for stealing $1.7 million from Local 657 of the Laborers’ International Union of North America. A union business agent was sentenced to 41 months in prison and ordered to pay more than $1 million in restitution to International Longshoremen’s Association Local 970 for unlawfully withdrawing dues payments and new member initiation fees. A New Jersey woman was sentenced to 84 months in prison for collecting more than $300,000 in unemployment insurance from the New Jersey Department of Labor and Workforce Development for filing false applications. These are some of the examples of the exceptional work done by our dedicated OIG staff. I would like to express my gratitude to them for their significant achievements during this reporting period. We continue to work on many important audits. For more details, I invite you to review our audit work plan for Fiscal Year 2017, which can be found in the appendix of this report. I look forward to continuing to work constructively with the Department and the Congress on our shared goals of identifying improvements to DOL programs and operations, and protecting the interests and benefits of workers and retirees
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Semi-Annual Report to Congress for the Period of October 1, 2016 to March 31, 2017
2017Co-Authors: Office Of The Inspector GeneralAbstract:[Excerpt] I am pleased to submit to Congress and the Department this Semiannual Report, which highlights the most significant activities and accomplishments of the U.S. Department of Labor (DOL), Office of Inspector General (OIG) for the six-month period ending March 31, 2017. Our audits and investigations continue to assess the effectiveness, efficiency, economy, and integrity of DOL’s programs and operations. We also continue to investigate the influence of labor racketeering and organized crime in internal union affairs, employee benefits plans, and labor-management relations, and have partnered with other law enforcement agencies on human trafficking matters. During this reporting period, the OIG issued 11 audit and other reports that, among other things, identified $26 million in monetary impact. Among our many significant findings, we reported the following: For the period January 1, 2014, to June 30, 2015, 11 of the 12 Job Corps centers reviewed did not contact law enforcement for 42 percent of potentially serious criminal misconduct incidents. At all 12 centers, we identified significant incidents that had not been reported to Job Corps. We also observed physical security weaknesses, such as inoperable closed-circuit television cameras and damaged or no fencing along center perimeters. Finally, Job Corps required pre-employment background checks for only a few center positions. The Mine Safety and Health Administration’s oversight of emergency response plans was insufficient in that all the plans we reviewed contained inaccuracies or omissions, placing miners at unnecessarily increased risk during an emergency. The Occupational Safety and Health Administration did not ensure employers took adequate and timely actions to correct hazards identified during inspections for an estimated 16 percent of the citations the agency issued in FY 2015. The Employee Benefits Security Administration did not have the ability to protect the estimated 79 million plan participants in self-insured Health plans from improper denials of Health claims, due to a lack of knowledge of claim denials in the plans under its oversight. During this reporting period the OIG’s investigative work yielded impressive results, with a total of 45 indictments, 116 convictions, and more than $41 million in monetary accomplishments. Highlights of our work include the following: Executives of a physical therapy company in Texas were convicted of Health Care Fraud, and other charges, for their roles in a scheme to bill DOL’s Office of Workers’ Compensation Programs more than $9.5 million for services that were not provided. The chief executive officer of a Maryland contracting company was sentenced to 68 months in prison for stealing $1.7 million from Local 657 of the Laborers’ International Union of North America. A union business agent was sentenced to 41 months in prison and ordered to pay more than $1 million in restitution to International Longshoremen’s Association Local 970 for unlawfully withdrawing dues payments and new member initiation fees. A New Jersey woman was sentenced to 84 months in prison for collecting more than $300,000 in unemployment insurance from the New Jersey Department of Labor and Workforce Development for filing false applications. These are some of the examples of the exceptional work done by our dedicated OIG staff. I would like to express my gratitude to them for their significant achievements during this reporting period. We continue to work on many important audits. For more details, I invite you to review our audit work plan for Fiscal Year 2017, which can be found in the appendix of this report. I look forward to continuing to work constructively with the Department and the Congress on our shared goals of identifying improvements to DOL programs and operations, and protecting the interests and benefits of workers and retirees.OIG_Semiannual_Report_to_Congress_v77.pdf: 46 downloads, before Oct. 1, 2020
Melissa Taormina - One of the best experts on this subject based on the ideXlab platform.
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the stark truth what your physician clients should know about stark law and the anti kickback statute
Journal of health care finance, 2013Co-Authors: Melissa TaorminaAbstract:This article summarizes key features of Stark Law and the Anti-Kickback Statute, statutes used to fight Health Care Fraud and abuse within MediCare and Medicaid, and explains how attorneys can help Health Care providers comply with these laws.
Anupam B Jena - One of the best experts on this subject based on the ideXlab platform.
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identifying outlier patterns of inconsistent ambulance billing in mediCare
Health Services Research, 2021Co-Authors: Prachi Sanghavi, Anupam B Jena, Joseph P Newhouse, Alan M ZaslavskyAbstract:OBJECTIVE To illustrate a method that accounts for sampling variation in identifying suppliers and counties with outlying rates of a particular pattern of inconsistent billing for ambulance services to MediCare. DATA SOURCES US MediCare claims for a 20% simple random sample of 2010-2014 fee-for-service beneficiaries. STUDY DESIGN We identified instances in which ambulance suppliers billed MediCare for transporting a patient to a hospital, but no corresponding hospital visit appeared in billing claims. We estimated the distributions of outlier supplier and county rates of such "ghost rides" by fitting a nonparametric empirical Bayes model with flexible distributional assumptions to account for sampling variation. DATA COLLECTION We included Basic and advanced life support ground emergency ambulance claims with a hospital destination. PRINCIPAL FINDINGS "Ghost ride" rates varied considerably across both ambulance suppliers and counties. We estimated 6.1% of suppliers and 5.0% of counties had rates that exceeded 3.6%, which was twice the national average of "ghost rides" (1.8% of all ambulance transports). CONCLUSIONS Health Care Fraud and abuse are frequently asserted but can be difficult to detect. Our data-driven approach may be a useful starting point for further investigation.
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characteristics of physicians excluded from us mediCare and state public insurance programs for Fraud Health crimes or unlawful prescribing of controlled substances
JAMA Network Open, 2018Co-Authors: Alice Chen, Anupam B Jena, Daniel M BlumenthalAbstract:Importance Each year, billions of dollars are wasted owing to Health Care Fraud, waste, and abuse. Efforts to detect Fraud have been increasing, yet we have little information about physicians who have been excluded from MediCare and state public insurance programs for Fraud, Health crimes, or the unlawful prescribing of controlled substances. Objective To examine the characteristics of physicians excluded from MediCare and state public insurance programs for Fraud, Health crimes, or unlawful prescribing of controlled substances. Design, Setting, and Participants This cross-sectional study considered all physicians excluded from MediCare and state public insurance programs between 2007 and 2017. The study matched exclusion data to a comprehensive, cross-sectional database of US physicians assembled by Doximity, an online networking service for US physicians. The share of physicians excluded in each state was examined and linear trends of exclusions over time were estimated. Using physician-level multivariable logistic regression models, exclusions (binary variable) were assessed as a function of physician characteristics. Main Outcomes and Measures Exclusions for Fraud, Health crimes (defined legally as criminal penalties for acts involving federal Health Care programs), and substance abuse; and physician characteristics, including age, sex, allopathic vs osteopathic degree, medical school attended, ranking of that medical school, medical school faculty affiliation, practice state, practice location, and specialty. Results Between 2007 and 2017, 2222 physicians (0.29%) were temporarily or permanently excluded from MediCare and state public insurance programs. Fraud, Health crimes, and substance abuse exclusions increased, on average, 20% per year (equivalent to 48 [95% CI, 40.4-56.0] convictions/year from a base of 236 convictions in 2007 to 670 convictions in 2017 [an increase of approximately 200% from 2007 to 2017]). Exclusion rates were highest in the West and Southeast. West Virginia had the highest exclusion rate, with 5.77 exclusions per 1000 physicians (32 exclusions among 5720 physicians), while Montana had 0 exclusions during this period. Male physicians, physicians with osteopathic training, older physicians, and physicians in specific specialties (eg, family medicine, psychiatry, internal medicine, anesthesiology, surgery, and obstetrics/gynecology) were more likely to be excluded. Conclusions and Relevance The number of physicians excluded from participation in MediCare and state public insurance reimbursement owing to Fraud, waste, and abuse increased between 2007 and 2017. Several physician characteristics, including being a male, older age, and osteopathic training, were significantly and positively associated with exclusion. Our results highlight the potential value of using physician characteristics in conjunction with information on medical claims filed by physicians to help identify adverse physician behavior.
Robb Degraw - One of the best experts on this subject based on the ideXlab platform.
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defining willful remuneration how bryan v united states affects the scienter requirement of the mediCare medicaid anti kickback statute
The Journal of Law and Health, 1999Co-Authors: Robb DegrawAbstract:I. INTRODUCTION The General Accounting Office and the Department of Health and Human Services (the "DHHS") recently estimated that MediCare pays $23 billion a year in Fraudulent medical claims. (1) Not surprisingly, many Health Care professionals consider MediCare Fraud and abuse the leading Health Care issue in 1999. (2) To combat the Fraud abuse in the system, Congress has recently enacted several new laws and given life to some old ones. For example, Congress recently passed the Stark laws (3) the 1981 Civil Monetary Penalties Law, (4) and the Health Insurance Portability and Accountability Act. (5) In addition, the False Claims Act, originally enacted in 1863 with a qui tam provision, has become a major force in assisting the government in discovering and prosecuting Fraudulent claims. (6) Considerable emphasis has also been placed on prosecuting Fraud and abuse under the federal MediCare and Medicaid anti-kickback statute. (7) This Note examines the recent split in federal courts' interpretation of the scienter requirement of the anti-kickback statute and how the Supreme Court's recent definition of "willfully" in Bryan v. United States, (8) will impact the mens rea requirement for conviction under the anti-kickback statute. State and federal anti-kickback laws aim to prohibit the exchange of remuneration for referrals of patients, goods, or services under publicly funded Health Care programs. The premise of these laws is if a medical professional has a financial incentive for referring patients, he is more likely to increase the number of services performed. This incentive, in turn, will lead to an overutilization of services, the unnecessarily depletion of program funds, and a waste of taxpayer dollars. (9) Although many state laws contain similar provisions, this Note focuses solely on the federal MediCare and Medicaid anti-kickback statute. (10) The anti-kickback statute has been the source of much controversy. Supporters of the law argue that it is necessary to punish providers who would contribute to the nation's spiraling Health Care costs by placing profit over the best interests of their patients. On the other hand, medical providers fear that the anti-kickback laws will punish "innocent" referral arrangements used throughout the industry. Furthermore, it has been argued that these arrangements may ultimately save taxpayers dollars because of the efficiencies which they create. (11) For example, if a hospital owns a management service organization (MSO) that furnishes support services to a physician practice, the hospital may be in violation of the anti-kickback statute if it charges less than the fair market value for the services it provides to the MSO on the theory that such savings are "remuneration" to induce referrals. (12) At the forefront of the debate over the anti-kickback statute, and the topic of this Note, is the mens rea, or mental state, that is required for a violation of the law. According to the statute, an individual must "knowingly and willfully" solicit or receive, or offer or pay, remuneration in order to induce business reimbursed under any federal Health Care program. (13) The interpretation of these terms by the federal courts has varied wildly, as have the underlying Supreme Court cases cited as precedent for such interpretations. However, in June of 1998, the Supreme Court defined the meaning of "willfully" under a federal criminal statute in Bryan v. United States. (14) Although the criminal statute in Bryan was unrelated to Health Care Fraud, the Eleventh Circuit has adopted the Bryan Court's definition of "willfully" in a case involving the anti-kickback statute. (15) Whether Bryan will resolve the split between the circuit courts is unclear; however, this case is certain to significantly influence the debate. The following Section of this Note briefly summarizes the legislative development of the federal anti-kickback statute including the 1980 amendment adding the mens rea requirement. …
Nonviolent Theft - One of the best experts on this subject based on the ideXlab platform.
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A Case Control Study: White-Collar Defendants Compared With Defendants Charged With Other
2016Co-Authors: Nonviolent TheftAbstract:We examined the clinical, criminal, and sociodemographic characteristics of all white-collar crime defendants referred to the evaluation unit of a state center for forensic psychiatry. With 29,310 evaluations in a 12-year period, we found 70 defendants charged with embezzlement, 3 with Health Care Fraud, and no other white-collar defendants (based on the eight crimes widely accepted as white-collar offenses). In a case-control study design, the 70 embezzlement cases were compared with 73 defendants charged with other forms of nonviolent theft. White-collar defendants were found to have a higher likelihood of white race (adjusted odds ratio (adj. OR) 4.51), more years of education (adj. OR 3471), and a lower likelihood of substance abuse (adj. OR .28) than control defendants. Logistic regression modeling showed that the variance in the relationship between unipolar depression and white-collar crime was more economically accounted for by education, race, and substance abuse. J Am Acad Psychiatry Law 34:82–9, 2006 Long recognized as a contrast to common crime, white-collar crime was defined initially as ‘‘crime committed by a person of respectability and high social status in the course of his occupation ” (Ref. 1, p 1). This definition evolved to “economic offense
