Bribery by any other name is still wrong
November 29th 2009 14:28
In the legislative branch of the US Government, they call it logrolling. But in reality, when all is said and done, it is bribery. They use our hard earned money taken at gunpoint from us to bribe other representatives to vote in favor of bad ideas. It costs the American people billions of dollars a year that we could be keeping in our pockets and using to stimulate the economy.
Just wait until the health care bill is finalized. It is already packed full of pork to get the votes for cloture, and everyone who didn't get anything yet is balking at the bill now in order to get some pork for themselves. The Baucus bill has the federal government paying the entire cost for the mandated Medicaid expansion in the following states: Nevada, Oregon, Rhode Island and Michigan. And let's not forget the 100 MILLION dollars for Louisiana's Medicaid system. This is an attempt to bribe or reward the Senators and Representatives from those states using my tax money.
Other states aren't getting this sweet deal. Citizens in the other 46 states will have to pay higher State taxes to fund this scheme. Frankly, I think any Congressional leader who offers a tax-funded benefit for a state or district in order to secure a vote, and any member of Congress who negotiates to gain such a benefit, should be brought up on charges and go to jail for violating the anti-bribery law.
The laws are supposed to treat all of us equally. Any law that treats citizens of some states differently is inherently unjust, and any law passed using tax-funded bribery is inherently unethical. I believe the so called health care bill is both things, unjust and unethical. Any of you who still think that this bill is going solve ANY problems with the health care system are fooling yourselves. It is yet another case of egotistical politicians telling bald faced lies to try and convince us that they can solve the problem with more government CONTROL over our lives. Don't drink the Kool-aid. Less government is the only way to solve the health care problem.
Just wait until the health care bill is finalized. It is already packed full of pork to get the votes for cloture, and everyone who didn't get anything yet is balking at the bill now in order to get some pork for themselves. The Baucus bill has the federal government paying the entire cost for the mandated Medicaid expansion in the following states: Nevada, Oregon, Rhode Island and Michigan. And let's not forget the 100 MILLION dollars for Louisiana's Medicaid system. This is an attempt to bribe or reward the Senators and Representatives from those states using my tax money.
Other states aren't getting this sweet deal. Citizens in the other 46 states will have to pay higher State taxes to fund this scheme. Frankly, I think any Congressional leader who offers a tax-funded benefit for a state or district in order to secure a vote, and any member of Congress who negotiates to gain such a benefit, should be brought up on charges and go to jail for violating the anti-bribery law.
The laws are supposed to treat all of us equally. Any law that treats citizens of some states differently is inherently unjust, and any law passed using tax-funded bribery is inherently unethical. I believe the so called health care bill is both things, unjust and unethical. Any of you who still think that this bill is going solve ANY problems with the health care system are fooling yourselves. It is yet another case of egotistical politicians telling bald faced lies to try and convince us that they can solve the problem with more government CONTROL over our lives. Don't drink the Kool-aid. Less government is the only way to solve the health care problem.
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Comment by Anonymous
Turning next to relators’ claims based on alleged violations of the Anti-Kickback Statute, the court concluded relators failed to allege “that United Health certified compliance with the Anti-Kickback Act, nor did they allege that such compliance was relevant to the Government's funding decisions.” The court then declined to exercise supplemental jurisdiction over relators’ state law claims and refused to grant relators leave to amend.
MEDICARE FRAUD, MEDICADE FRAUD, AND KICKBACKS AND BRIBES BUSINESS AS USUAL,INSIDER INFORMATION GIVEN. 9B BS ONE THING BUT WHAT ABOUT YOUR "HANDS OFF POLICY" BY THE DOJ AND CMS AND HHS, AND WHY NO INVESTAGATIONS OR AUDITS TO CONFIRM OR HELP? "SELF DISCLOSURE BY CARRIER ANOTHER JOKE".
WHAT ABOUT "TAXPAYERS TO PREVENT AND STOP AND PREVENT FRAUD FOR MEDICARE AND MEDICADE" WHAT ABOUT WILLIS AND WILKINS BEING FIRED FOR NOT WANTING TO BREAK THE HEALTH FRAUD LAWS?
NJ CEPA CLAIM NOW ON FILE.....FALSE CLAIM UNDER APPEAL AND FILED..... WHERE WAS ANY HELP FROM THESE DEPARTMENTS?
The U.S. District Court for the District of New Jersey dismissed May 13 a qui tam action alleging violations of the False Claims Act (FCA) by United Health Group and its subsidiaries. According to the court, the complaint failed to state a claim upon which relief could be granted under the FCA. Relator Charles Wilkins began employment with United Health Group and its subsidiary AmeriChoice in October 2007 as a sales representative. Relator Darryl Willis began employment with United Health Group and AmeriChoice in 2007 as the general manager for Medicare/Medicaid marketing and sales.
In their qui tam complaint, relators allege 11 violations of Medicare and Medicaid regulations. The United States declined to intervene in the case and the relators filed an amended complaint that stated one federal count—violation of 31 U.S.C. § 3729(a)(1)-(3)—and nine state law counts. United Health moved to dismiss under Fed. R. Civ. P. 12(b)(6), arguing relators failed to plead the elements of a "false certification" claim, they failed to plead any anti-kickback violations, and failed to adequately plead a conspiracy. Relators alleged that because United Health entered into a contract expressly certifying that it agreed with all "terms and conditions of payment," they made a false claim when they submitted claims despite any one of the 11 purported regulatory violations alleged in the amended complaint. Rejecting relators' express false certification claim, the court found “[not once in the Amended Complaint have Relators identified even a single claim for payment to the Government.”The court also held relators’ implied false certification claim failed. According to the court, relators argued that because United Health agreed to comply with all CMS regulations when it contracted to become a prescription drug plan sponsor, and because at times it was in violation of some regulations, it therefore committed fraud each time it submitted a claim for payment. The court found such a theory of liability overly broad. “If Relators' theory were correct, the FCA would become a federal tort fountain, flowing claims for every trivial violation of Medicare/Medicaid regulations,” the court said. Relators next argued that under the recently enacted Fraud Enforcement and Recovery Act of 2009 (FERA) a relator need only show whether compliance with regulations would have a tendency to influence the government's payment decision. While that argument is true, the court reasoned, “Relators must still show a claim . . . and [t]hey have not done so.” Turning next to relators’ claims based on alleged violations of the Anti-Kickback Statute, the court concluded relators failed to allege “that United Health certified compliance with the Anti-Kickback Act, nor did they allege that such compliance was relevant to the Government's funding decisions.” The court then declined to exercise supplemental jurisdiction over relators’ state law claims and refused to grant relators leave to amend.
United States ex rel. Wilkins v. United Health Grp. Inc., No. 08-3425 (D.N.J. May 13, 2010).
FCA claim alleging aggressive marketing tactics by health plan provider dismissed
Publication: Health Law Week
Date: Friday, June 4 2010
The U.S. District Court for the District of New Jersey dismissed a qui tam action brought by two former employees of healthcare plan providers alleging violations of the False Claims Act (FCA) arising from excessively aggressive marketing methods. United Health Group Inc., a provider of access to healthcare services, had as its subsidiaries AmeriChoice and AmeriChoice of New Jersey, which each offered Medicare Advantage plans. Charles Wilkins and Darryl Willis (the relators), who were each employed by United Health Group and AmeriChoice, initiated a qui tam claim against United and its two subsidiaries under the FCA alleging numerous violations of Medicare and Medicaid regulations governing administration of the Medicare Advantage plans. The complaint alleged that the defendants engaged in unauthorized and aggressive sales methods in marketing the plans -- including the provision of illegal cash payments to providers to induce them to change beneficiaries to AmeriChoice and the provision of illegal kickbacks to doctors for obtaining the names of patients they could call and approach. The defendants moved to dismiss.
The district court concluded that the complaint failed to identify a single instance in which the defendants submitted a false claim to the government for payment as required to prosecute a qui tam claim as relators under the FCA. Under applicable federal appellate court precedent, the absence of such an allegation was fatal to the relator's false certification claim. The relators' theory of liability at base was that because United Health agreed that it would comply with all Centers for Medicare and Medicaid Services regulations, and because it was at times in violation of some regulations, it committed fraud each time it submitted a claim for payment. The district court concluded that this contention confused the conditions of participation in a Medicare or Medicaid program with the conditions of payment, and would open the door to a flood of tort claims of a type not contemplated by the FCA. Moreover, the complaint failed to allege that the violation of any regulation was actually relevant to any funding decision. As a result, the complaint failed to state a claim on which relief could be granted and, accordingly, the defendants' motion to dismiss was granted.
Source: Health Law Week, 06/04/2010
Copyright © 2010 by Strafford Publications, Inc. http://www.straffordpub.com / All rights reserved. Storage, reproduction or transmission by any means is prohibited except pursuant to a valid license agreement.
Comment by Anonymous
Philadelphia PA Mayor Nutter received two years in a row $60,000 checks to help keep open and operate the city swimming pools.
These checks came from AmeriChoice Health and on the surface seems like fine gifts.
Yet, they are Bribes non the less, these checks come from a company who receives all its money from the Federal Government as a vendor for Medicare Medicaid services is not allowed to offer bribes kickbacks and money gifts of any kind in order to promote its share of the market place.
This is not allowed as a use of your taxpayers dollars yet it happens.What does it really cost the City of Philadelphia to receive this money?
Americhoice Health has a long history of corruption over the years yet seems to be protected by those who are responsible to over see their actions why is that?
Comment by Anonymous
It's true a licensed Health Agent was fired for his refusal to deliver these checks. It's true this behavior violates all the laws concerning bribes, kickbacks,fraud and Stark laws.
What is Bribery Any Way? a form of corruption,is an act implying money or gift given that alters the behavior of the recipient.
It's also true that the various Government agencies were notified of these frauds as well as a FCA case being filed. It's true this taint's all the business then received from Community health center to AmeriChoice Health Company and should be then held accountable and subject to all the violations of the health laws involved.
Has Bribery has become a normal way of doing business?
It's true that relators argued that because United Health agreed to comply with all those trivial regulations when it contracted to become a prescription drug plan sponsor,as well as sign a formal contract of compliance.
The court found such a theory of liability overly broad. “If Relators' theory were correct,the FCA would become a federal tort fountain, flowing claims for every trivial violation of Medicare/Medicaid regulations,”the court said. Relators next argued that under the recently enacted Fraud Enforcement and Recovery Act of 2009 (FERA) a relator need only show whether compliance with regulations would have a tendency to influence the government's payment decision.
While that argument is true, the court reasoned, “Relators must still show a claim . . . and they have not done so.”Turning next to relators’claims based on alleged violations of the Anti-Kickback Statute, the court concluded relators failed to allege “that United Health certified compliance with the Anti-Kickback Act, nor did they allege that such compliance was relevant to the Government's funding decisions.” The court then declined to exercise supplemental jurisdiction over relators’state law claims and refused to grant relators leave to amend.
It's true many additional laws were broken and proof furnished but no copy of checks to suppot the bribes etc.
I think the Federal courts have already decided that not only is Honest Fraud OK but Honest Bribes as well as Honest Kicbacks are OK. It's amazing a Federal Judge thinks bribes and kickbacks and fraud etc. are to trivial for the court system to waist their time on.
What should courts spend their time on and since when do you have to certify compliance for non-violation of the Federal And State Kickback laws??
Comment by Anonymous
The Washington Post
May 27, 2002
By Bill Brubaker
Anthony Welters grew up in a one-room tenement in Harlem, sleeping behind a curtain with his three brothers, he says. Today, he lives in a five-bedroom, seven-bathroom house on five acres in McLean. He has a 75-acre farm in the Blue Ridge Mountains. For a change of pace, there is a 5,000-square-foot house in Aspen, Colo., recently assessed at $3 million. Welters, 47, made his fortune in health insurance, serving a specialized market. The market is the poor. Federal and state audits concluded in the early and mid-1990s that ineffective oversight by Pennsylvania officials had enabled Welters and his partners to make too much money from their taxpayer-supported business. The audits said the Welters group had paid itself millions of dollars in management fees -- paid to other companies they controlled -- and millions more in bonuses.
Welters's health-insurance business expanded to New York in 1994 and New Jersey in 1996. In both states, the HMO was known as Managed Healthcare Systems (MHS). In New York, state investigators discovered something was not right about two clinics that MHS retained to serve patients in the borough of Brooklyn.
They determined that from 1995 to 1997 the clinics were being staffed largely by "unsupervised physician assistants or nurse practitioners," New York state Attorney General Eliot Spitzer announced in May 2000. The investigation also found that patients were "consistently complaining that they were having difficulty getting services or being seen by a doctor." MHS "failed to take any corrective action or properly oversee" the clinics. Spitzer announced a settlement in which MHS repaid more than $2 million to the Medicaid program for services the clinics never provided. In October 2000 MHS changed its name to AmeriChoice of New York. Anthony Welters, Chairman of AmeriChoice Corp.: "What [should] a person who takes a $200,000 investment and turns it into a billion-dollar company . . . receive? I don't know. But I know this: I'm not going to apologize for it."
Really Long Link
Comment: Medicaid's chronic under-funding threatens access to care for the low-income individuals covered by this program primarily because many providers will not participate at rates that frequently do not even pay overhead expenses. Several state governments have turned over their Medicaid funds to private corporations to administer these programs. Mr. Welters exemplifies how well these plans fulfill their corporate responsibility to their shareholders and executives.
Comment by Anonymous
John J. Kirchner - Director, Operations
John Kirchner joined Healthfirst in May 2010 with over 25 years experience in health care management. Mr. Kirchner’s background includes responsibility for health plan P&L, strategic planning and operations, and government and regulatory affairs. Mr. Kirchner will be responsible for supporting all aspects of NJ health plan operations.
Prior to joining Healthfirst, Mr. Kirchner held a variety of positions at AmeriChoice of New Jersey serving as President from 2007 through 2009. Mr. Kirchner also held Government Relations positions for Home Life Financial Assurance Corporation and Blue Cross and Blue Shield of New Jersey and served as Legislative Liaison for the New Jersey State Department of Health. Prior to beginning his career in health care, Mr. Kirchner served on the staff of US Senator Bill Bradley.
Mr. Kirchner received his BS Degree in Business Management from Stonehill College, Northeaston, MA.
Comment by History Buff
Most of Bill Thompson's "financial consulting" clients are not revealed on his Board of Ed disclosure forms. The most disturbing one that Thompson did list, however, was Managed Healthcare Systems Inc., where he earned a total of $65,000 in 1997 and 1998, according to his tax returns. A black-owned HMO whose principals worked at the highest levels of the Reagan administration, the company is shrouded in scandal.
Last year, New York Attorney General Eliot Spitzer forced the MHS, which specializes in recruiting Medicaid recipients for its HMO, to repay the state $2 million for Medicaid services that patients never received. Spitzer also put Jean Moise Millien, the director of an MHS clinic, in jail for up to three years after he pled guilty to stealing $275,000 from Medicaid. Spitzer's press release revealed that MHS knew for years that Millien's clinic, Stuyvesant Heights Medical Group, was largely run by "unsupervised physician's assistants and nurse practitioners" and that patients "were consistently complaining that they were having difficulty getting services."
Yet, said Spitzer, the company "failed to take corrective action or properly oversee its subcontractor." MHS portrayed itself as "a victim" of the clinic when they settled with Spitzer.
The State Health Department also revoked Millien's physician's assistant license in November 2000, finding that he'd run the clinic since 1991—four years before the MHS contract began—without on-site supervision by a licensed M.D. The Department also found that the clinic corporation had been dissolved by state officials for tax delinquency reasons in 1994 and that Millien had a prior criminal record. Spitzer said a doctor from Pennsylvania came to the clinic once a week "to sign charts" for a while, but "eventually stopped coming altogether."
An MHS affiliate left a similar trail of complaints in Pennsylvania—where it became the subject of Philadelphia Inquirerexposés in 1996 and 1997, before and during Thompson's employment. According to one study, it was three times as likely to refuse to pay for days of hospital care as the state's next most stingy HMO. The "focus of six special state and federal audits" and a onetime target of a Pennsylvania grand jury, according to the Inquirer,the company took a reported $119 million in profits and executive bonuses from its Pennsylvania Medicaid work alone in the early '90s, making it the "most profitable HMO" in the state.
Anthony Welters, the principal owner of AmeriChoice, the Virginia-based parent of MHS, was a top Reagan transportation official, gave $20,000 to Pennsylvania GOP governor Tom Ridge, and has given over $56,000 in recent years to Republican candidates and committees across the country. Clarence Thomas is the godfather of one of his children. Thelma Duggin, another top executive, worked in the Reagan White House and at the Republican National Committee under Lee Atwater, the engineer of the Willie Horton campaign.
Thompson said he'd known Welters and Duggin since 1992, when they started trying to do business in Brooklyn, and that he "bumped into Tony" in 1997 and Welters offered him a consulting job that started that June. Charged with "reaching out and helping them obtain business," Thompson said he "spoke to community organizations." Though he says he "never visited an MHS clinic"—including the Stuyvesant Heights one near his home—he insists that MHS is "a good company." While Thompson's tax returns indicate that AmeriChoice paid him $35,000 in 1998, his disclosure forms report no income from the company.
Thompson is quick to point out that he wasn't the only prominent Brooklyn Democrat to wind up on the MHS payroll. Assemblyman Al Vann was hired, as was DeCosta Headley, a Democratic district leader, Ed Miller, a campaign aide of Congressman Ed Towns, and Chris Owens, the son of Congressman Major Owens. "I don't think Al and Chris are getting involved in anything that's not 100 percent benefit to the community," said Thompson, apparently oblivious to the higher standard demanded of a candidate for so powerful a citywide post as comptroller.
Comment by Anonymous
Clarence Thomas (born June 23, 1948) is an Associate Justice of the Supreme Court of the United States since being appointed in 1991. Thomas is the second African American to serve on the Court, after Thurgood Marshall, whom he succeeded.
Thomas grew up in Georgia and was educated at the College of the Holy Cross and at Yale Law School. In 1974, he was appointed an Assistant Attorney General in Missouri and subsequently practiced law there in the private sector. In 1979, he became a legislative assistant to Missouri Senator John Danforth and in 1981 was appointed Assistant Secretary for Civil Rights at the U.S. Department of Education. In 1982, President Ronald Reagan appointed Thomas Chairman of the Equal Employment Opportunity Commission (EEOC) and he served in that position until 1990, when President George H. W. Bush nominated him for a seat on the United States Court of Appeals for the District of Columbia Circuit.
After one year and four months of service on the D.C. Circuit Court of Appeals, Bush nominated Thomas to fill the seat on the United States Supreme Court being vacated by Thurgood Marshall. Thomas's confirmation hearings were bitter and intensely fought, centering on an accusation that he had made unwelcome sexual comments to attorney Anita Hill, a subordinate at the Department of Education and subsequently at the EEOC. The U.S. Senate ultimately confirmed Thomas by a vote of 52–48.
Since joining the Court, Thomas has taken a textualist approach to judging, seeking to uphold what he sees as the original meaning of the United States Constitution and statutes. He is generally viewed as among the most conservative members of the Court. Thomas has often approached federalism issues in a way that limits the power of the federal government and expands power of state and local governments. At the same time, Thomas's opinions have generally supported a strong executive branch within the federal government.
Comment by Anonymous
“United's AmeriChoice unit is the largest government contractor administering state Medicaid programs for the poor and federally sponsored plans for children. AmeriChoice's revenue rose 34 percent last year, to $6 billion, and it has 2.7 million people enrolled.
Those numbers should continue rising under reform since congressional Democrats are proposing an expansion of Medicaid to help achieve universal coverage.
More of the working poor would qualify for Medicaid, and AmeriChoice can sell itself to states as the leading service provider
I have a question when you pay Doctors Commissions (kickbacks) or Clinics/Mayors Gifts (bribes) what accounting columns are these items placed in?
Certainly not bribes/kickbacks as a heading maybe sales expenses or some other type of cost of doing business heading, about loss? well, even that has a write off aspect to it.
So lets think about this as a outsider here we have a Medicaid contractor who receives all its money from the government / taxpayors and uses it for kickbacks and bribes then can turn around and write off that usage.
Well. One would have to say hats off to Ameri-Choice Health who is by far the most successful taxpayer story there is.... Where are all the Government /Taxpayor watch dog groups at that allowed this to happen?
How many companies who are not involved in oil can say they are enjoying the good life from this tax view point?
Government success story? Political success story? Taxpayor success story? its up to you to decide.
Comment by Anonymous
They were allready found guilty for violations of the FCA once and it did not do any good.
They came back for more.These laws are old laws not even the more strick ones, what more
do these Judges NEED IN ORDER TO DO THEIR JOB[/B]
Federal Register: December 19, 1994
What Is the Medicare and Medicaid Anti-Kickback Law?
Among its provisions, the anti-kickback statute penalizes anyone who knowingly and willfully solicits, receives, offers or pays remuneration in cash or in kind to induce, or in return for A. Referring an individual to a person for the furnishing, or arranging for the furnishing, of any item or service payable under the Medicare or Medicaid program; or B. Purchasing, leasing or ordering , or arranging for or recommending purchasing, leasing or ordering, any goods, facility, service or item payable under the Medicare or Medicaid program. Violators are subject to criminal penalties, or exclusion from participation in the Medicare and Medicaid rograms, or both.
A violation of the anti-kickback law is a felony offense that carries criminal fines of up to $25,000 per violation, imprisonment for up to five years and exclusion from government health care programs.
The federal anti-kickback statute, 42 U.S.C. § 1320a-7b(b), prohibits individuals or entities from knowingly and willfully offering, paying, soliciting or receiving remuneration to induce referrals of items or services covered by Medicare, Medicaid or any other federally funded program.
Comment by Tax Dollars
Three years ago they were reported to these agencys and as of todays date not only were they allowed to continue doing business but were never charged once.
Protected vendor status sure, politics sure, limited government budgets sure, Federal and State officals looking the other way sure, and rather then stop these activities a strong desire not to rock the boat exist. Even with the vast changes in rhe laws and budgets,a hands off policy remains, you tell me what's wrong with this picture?
The Government created this monster and now they don't know what to do about it, like shooting yourself in your own foot etc.Tons of money to advance their national growth, its market positions, tons of money for political donations, tons of money to send 75 millon back to its home office from New York state alone, tons of money to suppot National TV shows, tons of money to pay hugh State fines, tons of money to hire the very best law firms, tons of money to pay for bribes and kickbacks, tons of money for hugh salarys and bonuses, all done on the back of the American taxpayor, you see this company receives all its money from the Federal government.
Should your tax dollars it be held to a higher standard? Should the government agencys responsible for there review be held to that same standard? Should the IRS audit their corruption? Why has this company not been charged?
How long can the buck be passed here in more ways then one? Hey, it's your tax dollars don't complain now.. then don't complain later on...
Comment by Anonymous
The transportation used were 'limo-carriers' from the Newark area.This also seems like a great idea to help those who can't help themselves of course its with the taxpayer who foots this bill for these benefits as well as the many others offered under the Plan. This Limo-services supplied a pick up service and and return service for the duel beneficiarys to go to their Doctors, get their prescriptions filled, grocery shopping, and once a month to go to a free movie at a local Newark theater once again all on the back of the taxpayer. Their Brochure goes on to say when you enroll with AmeriChoice Personal Care Plus you get more benefits, and more coverage,more personalized care and more services than Medicaid and Original Medicare.
I'm not attacking the poor or any of these wonderfull programs beng offered for medicare and medicaid folks, I'm sure these benefits were well thought out and by those responsible for such thrifty decisions etc. But I would like to question the grocery trips and theater trips and how this all relates to any taxpayors interest, All these new great Audit teams that report to CMS now, I'm sure if they uncover any thing wrong, it will be brought to our attention and corrected if necessay and any taxpayors money loss will be returned then will be protected.
I would like to know how this is not considered a major inducement under the Medicaid rules and regulations, you know to get those millions of Americans signed up that AmeriChoice Health keeps talking about. I wonder what roll the States play in this limo matter, and if Congress really knows how these tax dollars are being spent on limos to go to the movies?
Comment by Anonymous
The problem occurs when writing one up to come on board with AmerIChoice Health a second application is written for this above benefit even though they have not been accepted into the AmeriChoice health plan. It sounds to be a minor issue buts its not, you see this benefit and its application for this benefit are completed at the very same time the application is written for AmeriChoice Health. Now , remember your dealing with older Americans and their mind is on the "Response Emergency System etc. and you have used..... this benefit..... as a formal inducement...and even took an application on it so as to have them change.
This is against all the Inducement rules regulations and laws.This matter was brought to everyone's attention both inside and outside of AmeriChoice yet, is was as all else ignored. The refusal by the company to conform and not take an application for this benefit till they were approved with AmeriChoice started to set the mood ongoing for many terminations, and yes I was fired. This was only one of dozens of rules laws and or violations that were brought to their attention as well as the federal agency's outside their Home Office In Newark and ignored.
Here are few things that were told to me, don't rock the boat, nobody cares, Take you pay check and keep your mouth shut, will have you report early everyday in Newark before you day starts and or you will have report late at night until you understand your position with the company, we will delay or not approve expenses and on and on etc. I was even told by a person who worked at CMS I would be the one in trouble for making these violations a big deal .... The problem was as a licensed agent it violated all the laws rules and regulations that controlled my license and any sales effort including the use of their illegal forms being used. A Federal Judge reviewed these issues as well as others and thought them trivial, I was very sorry to hear this since it cost me as well as others, our jobs.
If the Inducement laws are not going to be enforced why do you need licensed agents to market the products? Thousands of tainted sales being made and yes its true nobody cares.
Comment by Anonymous
The difference in the law as applied to a "person vs a corporation" on one hand the corporation, has a formal contract signed with the government not to break the health laws,, rules and regulations, so any violations that occur now become trivial, as well as evidence recovery denied, jury trial denied, and of course any claims submitted to the government really don't exist. The person a doctor not a corporation, jury trial allowed, evidence gatherning allowed, of course no formal contract signed with the government his mistakes are real. The very same laws ,rules and regualtions in place apply to both but this means that any person is now screwed and must go to jail.There are a lot of lessons to learn from this unfortunately don't violate the law is not one of them.
It’s true that relators argued that because United Health agreed to comply with all those trivial regulations when it contracted to become a prescription drug plan sponsor,as well as sign a formal contract of compliance. The court found such a theory of liability overly broad. “If Relators’ theory were correct,the FCA would become a federal tort fountain, flowing claims for every trivial violation of Medicare/Medicaid regulations,”the court said. Relators next argued that under the recently enacted Fraud Enforcement and Recovery Act of 2009 (FERA) a relator need only show whether compliance with regulations would have a tendency to influence the government’s payment decision. While that argument is true, the court reasoned, “Relators must still show a claim . . . and they have not done so.”Turning next to relators’claims based on alleged violations of the Anti-Kickback Statute, the court concluded relators failed to allege “that United Health certified compliance with the Anti-Kickback Act, nor did they allege that such compliance was relevant to the Government’s funding decisions.” The court then declined to exercise supplemental jurisdiction over relators’state law claims and refused to grant relators leave to amend.
Case1
Fifth Circuit Ruling Affirms that Psychologists are Not immune from Fraud and Abuse Scrutiny September 6, 2010 Posted In: Compliance , Stark and Anti-Kickback By The Health Law Partners on September 6, 2010 9:13 AM | Permalink
Dr. Sam Smith Hill, III's 2008 healthcare fraud conviction was affirmed by the 5th Circuit on August 25, 2010 (US v. Hill, No. 09-40749 (5th Cir. Aug. 25, 2010). Found guilty in five counts of healthcare fraud by a jury, Dr. Hill's indictment alleged that he fraudulently billed Medicaid from 2001 to 2008. Having founded a children's behavioral clinic in Corpus Christi, Texas that provides psychological services to underprivileged children, the indictment contended that Dr. Hill billed Medicaid for services performed by his Licensed Psychological Associates (LPAs). The Texas Medicaid guidelines prohibit billing Medicaid for services not rendered by a physician. Dr. Hill asserted that he only billed for the work he performed; however, the 5th Circuit disagreed, citing Dr. Hill's statements to FBI agents claiming "that he knew he was violating Medicaid billing rules, but that the rules were 'wrong and immoral.'" The court, thus, found there to be "sufficient evidence from which the jury could conclude that the billing included the LPA time," affirming the lower court's conviction.
While not given as much attention as other fraud and abuse violations, even mental health professionals must be aware of increased fraud and abuse scrutiny.
For more information, please contact Abby Pendleton, Esq. or Robert S. Iwrey, Esq. at (248) 996-8510, or visit the Fraud and Abuse specialty page, the Compliance specialty page, or the HLP website.
Case2
FCA claim alleging aggressive marketing tactics by health plan provider dismissed
Publication: Health Law Week
Date: Friday, June 4 2010
The U.S. District Court for the District of New Jersey dismissed a qui tam action brought by two former employees of healthcare plan providers alleging violations of the False Claims Act (FCA) arising from excessively aggressive marketing methods. United Health Group Inc., a provider of access to healthcare services, had as its subsidiaries AmeriChoice and AmeriChoice of New Jersey, which each offered Medicare Advantage plans. Charles Wilkins and Darryl Willis (the relators), who were each employed by United Health Group and AmeriChoice, initiated a qui tam claim against United and its two subsidiaries under the FCA alleging numerous violations of Medicare and Medicaid regulations governing administration of the Medicare Advantage plans. The complaint alleged that the defendants engaged in unauthorized and aggressive sales methods in marketing the plans -- including the provision of illegal cash payments to providers to induce them to change beneficiaries to AmeriChoice and the provision of illegal kickbacks to doctors for obtaining the names of patients they could call and approach. The defendants moved to dismiss. The district court concluded that the complaint failed to identify a single instance in which the defendants submitted a false claim to the government for payment as required to prosecute a qui tam claim as relators under the FCA. Under applicable federal appellate court precedent, the absence of such an allegation was fatal to the relator's false certification claim. The relators' theory of liability at base was that because United Health agreed that it would comply with all Centers for Medicare and Medicaid Services regulations, and because it was at times in violation of some regulations, it committed fraud each time it submitted a claim for payment. The district court concluded that this contention confused the conditions of participation in a Medicare or Medicaid program with the conditions of payment, and would open the door to a flood of tort claims of a type not contemplated by the FCA. Moreover, the complaint failed to allege that the violation of any regulation was actually relevant to any funding decision. As a result, the complaint failed to state a claim on which relief could be granted and, accordingly, the defendants' motion to dismiss was granted.
Source: Health Law Week, 06/04/2010
Copyright © 2010 by Strafford Publications, Inc. http://www.straffordpub.com / All rights reserved. Storage, reproduction or transmission by any means is prohibited except pursuant to a valid license agreement. "
Comment by Chicken Gate
In September, insurance company AmeriChoice brings trucks to blighted neighborhoods in New York City and gives away coupons for "free chickens" as an incentive for the underprivileged to switch their Medicare coverage. New York state senator Carl Kruger files a complaint with the state attorney general. The 101 Dumbest Moments In Business 2003 EDITION - April 1, 2003 Apr 1, 2003 ... Just don't tell him about the "Chinese health balls." ..... In September, insurance company AmeriChoice brings trucks to blighted ... New York state senator Carl Kruger files a complaint with the state attorney general..... Falling on his sword, Welch announces he'll give up most of the perks,...2009 and 2010 $120,000 from your tax dollars.
Philadelphia PA Mayor Nutter received two years in a row $60,000 checks to help keep open and operate the city swimming pools. These checks came from AmeriChoice Health and on the surface seems like fine gifts. Yet, they are Bribes non the less, these checks come from a company who receives all its money from the Federal Government as a vendor for Medicare Medicaid services is not allowed to offer bribes kickbacks and money gifts of any kind in order to promote its share or induce its share of the market place. This is not allowed as a use of your taxpayers dollars, yet it happens.What does it really cost the City of Philadelphia to receive this money? Americhoice Health has a long history of corruption over the years yet seems to be protected by those who are responsible to over see their actions why is that? PS... Did the Mayor send for Chicken Man or was he approched by Chicken Man? The Mystery Widens! Can Chicken Man save the Liabraries?
CEO of AmeriChoice Health Bolts.. Was that Chicken Man? John J. Kirchner - Director, Operations John Kirchner joined Healthfirst in May 2010 with over 25 years experience in health care management. Mr. Kirchner’s background includes responsibility for health plan P&L, strategic planning and operations, and government and regulatory affairs. Mr. Kirchner will be responsible for supporting all aspects of NJ health plan operations. Prior to joining Healthfirst, Mr. Kirchner held a variety of positions at AmeriChoice of New Jersey serving as President from 2007 through 2009.
Will this mystery man or woman or chicken ever be caught? Will the "secret eggs" given out to housing authority officers Clinics, Doctors and whoever, make it into through that crispy crust prepared by their Home Office Line Chefs?. Will the Doctors who collected all those extra eggs for sharing thier patients recipes with the Home Office Line Chefs ever really be rewarded? Will the Great Head Chef Chicken Man or whomever that directed and approved all to avoid, overlook the rules, laws and regulations Menu, ever be really compensated for their true worth or will Salmonella remain the dish served for Medicare and Mediciad Industry.
PS Is the Chicken Man a Blues Brothers Wanna B???
Comment by Dont Understand
Posted: November 24, 2000
Re: OIG Advisory Opinion No. 00-7
Health care providers that offer free goods or services, such as free transportation services, to Federal health care beneficiaries may be subject to civil monetary penalties. In section 1128A(a)(5) of the Act, Congress specifically addressed the issue of providers offering remuneration to Medicare and Medicaid beneficiaries in order to influence their selection of a particular provider by authorizing the imposition of civil monetary penalties against such providers. Moreover, free transportation services may implicate the criminal anti-kickback statute which prohibits offering anything of value to any "person" (including a Federal health care beneficiary) to reward or induce referrals (including self-referrals) for items or services reimbursable under any Federal health care program.(1) Given the overlap between the two statutes, we will begin with some general observations about free transportation services.(2)
First, we recognize that many arrangements involving free transportation have important and beneficial effects on patient care, especially where such arrangements are narrowly tailored to address issues of financial need, limited transportation resources, treatment compliance, or safety.
Second, we also recognize that free transportation services are sometimes an integral part of fraudulent or abusive schemes which lead to inappropriate steering of patients, overutilization, and the provision of medically unnecessary services. Examples of abusive arrangements involving free transportation services include:
Psychiatric facilities offering out-of-state patients free round-trip airline tickets to Florida in order to receive services at their facilities;
Van drivers soliciting, and offering free transportation services to, Medicaid patients for health care providers who compensate the drivers on a per patient or per service basis;
Unscrupulous health care providers offering residents of nursing facilities and other congregate care facilities free transportation services to and from their offices for services that are frequently of questionable necessity;
Hospitals offering patients free limousine services; and
Hospitals offering patients free ambulance services without making individual determinations of financial need.
Third, given their potential for abuse, we evaluate arrangements involving free transportation services on a case-by-case basis. We have identified several risk factors including, but not limited to, the following:
The population to whom free transportation services are offered. While free transportation services offered to "all comers" can implicate section 1128A(a)(5) of the Act and the anti-kickback statute, so can free transportation services offered to select patients or populations. To the extent the services are offered selectively, we evaluate the basis on which the selection is made. For example, an offeror of free transportation services might select individuals based upon one or more of the following criteria: relationship with the offeror (including physician-patient relationships); relationship with other providers (including nursing facility-resident relationships); diagnosis; insurance coverage; geographic location; financial need; or concerns regarding safety or treatment compliance.
The nature or type of free transportation services offered. Expensive transportation services such as limousines, airline tickets, or ambulance transports raise greater concerns.
The geographic area in which free transportation services are offered. Services offered within a provider's historic service area are less suspect than services offered outside its historic service area.
The availability and affordability of alternate means of transportation.
Whether free transportation services are marketed or advertised and, if so, how.
The type of provider offering the free transportation services. Free transportation services offered by individual or small groups of providers, including physicians, or by freestanding clinics are subject to greater scrutiny. Historically, unscrupulous providers and clinics have offered free transportation services in conjunction with Medicare and Medicaid mills.
Whether the costs of the free transportation services will be claimed directly or indirectly on any Federal health care program cost report or claim or otherwise shifted to any Federal health care program.
These factors are not exclusive, and the presence or absence of any one factor is not determinative of whether the OIG would subject parties to sanctions for providing free transportation services to patients.
Fourth, we weigh these factors, as well as other relevant concerns, in assessing the level of risk presented by an arrangement. They are not necessarily determinative or probative of whether an arrangement violates the applicable statutes. The elements required for a violation of the statutes are discussed below.
B. Application of Section 1128A(a)(5) of the Act
Section 1128A(a)(5) of the Act provides for the imposition of civil monetary penalties against any person who:
offers or transfers remuneration to any individual eligible for benefits under [Medicare or a State health care program] that such person knows or should know is likely to influence such individual to order or receive from a particular provider, practitioner, or supplier any item or service for which payment may be made, in whole or in part, under [Medicare or a State health care program].
See also 65 Fed. Reg. 24400, 24416 (April 26, 2000) (to be codified at 42 C.F.R. § 1003.102(b)(13)). Section 1128A(i)(6) of the Act defines "remuneration" for purposes of section 1128A(a)(5) of the Act as including, among other things, "transfers of items or services for free or for other than fair market value." Unlike the anti-kickback statute, section 1128A(a)(5) of the Act is solely concerned with remuneration offered or transferred to Medicare or State health care program beneficiaries.
Although free transportation services clearly fall within the ambit of the prohibition, legislative history indicates that, in enacting section 1128A(a)(5), Congress did not intend to impose civil monetary penalties against persons offering complimentary local transportation of nominal value. H.R. Conf. Rep. No. 104-736, at 255 (1996). In the preamble to 42 C.F.R. § 1003.102(b)(13), the final rule addressing section 1128A(a)(5) of the Act, we interpreted nominal value for purposes of section 1128A(a)(5) to be no more than $10 per item, or $50 in the aggregate on an annual basis. 65 Fed. Reg. 24400, 24411 (April 26, 2000). Moreover, we theorized that "frequent rendering of items or services to any individual may preclude such items and services from being classified as nominal in value." Id. at 24407. However, many free transports, including many of those provided under the Arrangement, exceed the nominal value and local service limits.
Notwithstanding, for all of the following reasons, we will not subject Hospital X to civil monetary penalties under section 1128A(a)(5) of the Act in connection with the Arrangement:
There is either limited or no economical means of public transportation in the geographic area where Hospital X provides the free transportation services.
The free transportation services are not advertised and are available only to individuals who have already been referred to, or are being treated at, Hospital X.
The free transportation services are available only if there has been an individualized determination of need (i.e., the patient has no other regular and reliable means of transportation).
The free transportation services are available to all qualified patients who require a course of multiple treatments, subject to available resources. The Arrangement is not limited to, or targeted at, particular profitable treatments or patient populations.
The costs of the free transportation services will not be claimed directly or indirectly on any Federal health care program cost report or claim or otherwise shifted to any Federal health care program.
The geographic area within which the free transportation services are offered is limited to Hospital X's historic primary service area, the size of which is determined in part by its rural location, and other areas that include patients for whom Hospital X is the nearest provider of the prescribed treatments.
Consistent with Hospital X's not-for-profit mission, the Arrangement provides a benefit to the community by giving elderly and low-income Hospital X patients access to medically necessary, life-prolonging treatments that they may otherwise forego, in whole or in part, because of inadequate transportation.
C. Application of the Anti-Kickback Statute
The anti-kickback statute makes it a criminal offense knowingly and willfully to offer, pay, solicit, or receive any remuneration to induce referrals of items or services reimbursable by any Federal health care program. See section 1128B(b) of the Act. Specifically, the statute provides that:
Whoever knowingly and willfully offers or pays [or solicits or receives] any remuneration (including any kickback, bribe, or rebate) directly or indirectly, overtly or covertly, in cash or in kind to any person to induce such person -- to refer an individual to a person for the furnishing or arranging for the furnishing of any item or service for which payment may be made in whole or in part under a Federal health care program, or to purchase, lease, order, or arrange for or recommend purchasing, leasing, or ordering any good, facility, service, or item for which payment may be made in whole or in part under a Federal health care program, shall be guilty of a felony.
Id. Thus, where remuneration is paid purposefully to induce referrals of items or services for which payment may be made by a Federal health care program, the anti-kickback statute is violated. By its terms, the statute ascribes criminal liability to parties on both sides of an impermissible "kickback" transaction. For purposes of the anti-kickback statute, "remuneration" includes the transfer of anything of value, in cash or in-kind, directly or indirectly, covertly or overtly.
The statute has been interpreted to cover any arrangement where one purpose of the remuneration was to obtain money for the referral of services or to induce further referrals. United States v. Kats, 871 F.2d 105 (9th Cir. 1989); United States v. Greber, 760 F.2d 68 (3d Cir.), cert. denied, 474 U.S. 988 (1985). Violation of the statute constitutes a felony punishable by a maximum fine of $25,000, imprisonment up to five years, or both. Conviction will also lead to automatic exclusion from Federal health care programs, including Medicare and Medicaid. The OIG may also initiate administrative proceedings to exclude persons from Federal and State health care programs or to impose civil monetary penalties for fraud, kickbacks, and other prohibited activities under sections 1128(b)(7) and 1128A(a)(7) of the Act.
Remuneration from a hospital to a patient that is intended to induce the patient to obtain hospital services implicates the anti-kickback statute. For example, the routine waiver of Medicare Part B coinsurance -- a payment obligation required by Federal law -- implicates the anti-kickback statute, as would offers of cash or other valuable gifts that are intended to induce patients to order services paid for in whole or in part by a Federal health care program. Free transportation services offered by a hospital to Federal health care program beneficiaries may have monetary value and implicate the anti-kickback statute, if the requisite intent to induce self-referrals is present. Notwithstanding, in the instant case, for all of the reasons set forth above in the analysis of section 1128A(a)(5) of the Act, we will not subject Hospital X to sanctions for violations arising under the Federal anti-kickback statute in connection with the Arrangement.
III. CONCLUSION
For all of the above reasons, and based on the information provided, we conclude that: (i) the OIG will not impose a civil monetary penalty under section 1128A(a)(5) of the Act on Hospital X in connection with the Arrangement, as described and certified in your request letter and supplemental submissions; and (ii) the Arrangement could potentially generate prohibited remuneration under the anti-kickback statute if the requisite intent were present, but that the OIG will not subject Hospital X to sanctions for violations of the anti-kickback statute under sections 1128(b)(7) or 1128A(a)(7) of the Act in connection with the Arrangement, as described and certified in your request letter and supplemental submissions.
IV. LIMITATIONS
The limitations applicable to this opinion include the following:
This advisory opinion is issued only to Hospital X, who is the requestor of this opinion. This advisory opinion has no application, and cannot be relied upon, by any other individual or entity.
This advisory opinion may not be introduced into evidence in any matter involving an entity or individual that is not a requestor to this opinion.
This advisory opinion is applicable only to the statutory provisions specifically noted above. No opinion is herein expressed or implied with respect to the application of any other Federal, state, or local statute, rule, regulation, ordinance, or other law that may be applicable to the Arrangement.
This advisory opinion will not bind or obligate any agency other than the U.S. Department of Health and Human Services.
This advisory opinion is limited in scope to the specific arrangement described in this letter and has no applicability to other arrangements, even those which appear similar in nature or scope.
No opinion is expressed herein regarding the liability of any party under the False Claims Act or other legal authorities for any improper billing, claims submission, cost reporting, or related conduct.
This opinion is also subject to any additional limitations set forth at 42 C.F.R. Part 1008.
The OIG will not proceed against the Requestor with respect to any action that is part of the Arrangement taken in good faith reliance upon this advisory opinion as long as all of the material facts have been fully, completely, and accurately presented, and the Arrangement in practice comports with the information provided. The OIG reserves the right to reconsider the questions and issues raised in this advisory opinion and, where the public interest requires, rescind, modify or terminate this opinion. In the event that this advisory opinion is modified or terminated, the OIG will not proceed against the Requestor with respect to any action taken in good faith reliance upon this advisory opinion, where all of the relevant facts were fully, completely, and accurately presented and where such action was promptly discontinued upon notification of the modification or termination of this advisory opinion. An advisory opinion may be rescinded only if the relevant and material facts have not been fully, completely and accurately disclosed to the OIG.
Sincerely,
/s/
D. McCarty Thornton
Chief Counsel to the Inspector General
FOOTNOTES:
1. Because both the criminal and administrative sanctions related to the anti-kickback implications of the Arrangement are based on violations of the anti-kickback statute, the analysis for purposes of this advisory opinion is the same under both.
2. Providers offering transportation services to beneficiaries at a price that is below fair market
Comment by Medicaid Pool Beneficiaries
AmeriChoice is proud to collaborate with Mayor Nutter’s administration for the second consecutive year to help overcome the obstacles that could have resulted in the City closing its pools this summer,said Executive Director of Pennsylvania East AmeriChoice Ernie Monfiletto.Following the check presentation, AmeriChoice was presented with a health care Innovation Award by the National Association of Health Services Executives in recognition of its services to its Medicaid and Children’s Health Insurance (CHIP) members. Hey, and this is all on film with current and potential beneficiaries applauding.
2009 and 2010 $120,000 blatant inducements from your tax dollars for the protected Medicaid vendor. Philadelphia PA Mayor Nutter received two years in a row $60,000 checks to help keep open and operate the city swimming pools. These checks came from AmeriChoice Health and on the surface seems like fine gifts.Yet, they are Bribes non the less, these checks come from a company who receives all its money from the Federal Government as a vendor for Medicare Medicaid services is not allowed to offer bribes kickbacks and money gifts of any kind inducements in order to promote its share of the market place. This is not allowed as a use of your taxpayers dollars yet it happens.What will it really cost the City of Philadelphia to receive this money? Americhoice Health has a long history of corruption over the years yet seems to be protected by those who are responsible to over see their actions why is that? Inducement. Section 1128A(a)(5) of the Act bars the offering of remuneration to Medicare or Medicaid beneficiaries where the person offering the remuneration knows or should know that the remuneration is likely to influence the beneficiary to order or receive items or services from a particular provider. The "should know" standard is met if a provider acts with deliberate ignorance or reckless disregard. No proof of specific intent is required. (See 42 CFR 1003.101.)
Among its provisions, the anti-kickback statute penalizes anyone who knowingly and willfully solicits, receives, offers or pays remuneration in cash or in kind to induce, or in return for: A. Referring an individual to a person for the furnishing, or arranging for the furnishing, of any item or service payable under the Medicare or Medicaid program; or B. Purchasing, leasing or ordering , or arranging for or recommending purchasing, leasing or ordering, any goods, facility, service or item payable under the Medicare or Medicaid program. Violators are subject to criminal penalties, or exclusion from participation in the Medicare and Medicaid rograms, or both. A violation of the anti-kickback law is a felony offense that carries criminal fines of up to $25,000 per violation, imprisonment for up to five years and exclusion from government health care programs.The federal anti-kickback statute, 42 U.S.C.§ 1320a-7b(b), prohibits individuals or entities from knowingly and willfully offering, paying, soliciting or receiving remuneration to induce referrals of items or services covered by Medicare, Medicaid or any other federally funded program. For purposes of the anti-kickback statute, "remuneration" includes the transfer of anything of value, directly or indirectly, overtly or covertly, in cash or in-kind
If this were any one person they would be in jail now, if the FBI were called in on this matter they would be in jail now, if the IRS were notified they would be in jail now. Since all Ameri-Choice checks come from the United Health's home office they should be held equally responsible for any bribes, kickbacks, Stark, Fraud and inducements violations that have occured. Federal and State Governments have developed such a depended position with this company that laws and rules no longer apply for them.This role is nothing new for the AmeriChoice people and its been going on for years, look at some of the prior news articles that date back for years only now they can afford to hire the best of Law firms and give the most for Political contributations all on the back of the taxpayer.
Comment by Medicaid Madness
AmeriChoice of New Jersey is sponsoring or participating in 22 events at community health centers, in support of National Health Center Week, August 9-15, led by the National Association of Community Health Centers (NACHC). “As a partner with the New Jersey Department of Human Services in Medicaid, Personal Care Plus and NJ Family Care, we are committed to improving access to quality, affordable health care for the most vulnerable populations in America,” said John Kirchner, AmeriChoice of New Jersey president. Community Health Centers serve 18 million people at more than 7,000 sites nationwide, providing quality health care, supported by AmeriChoice corporate parent, UnitedHealth Group. About AmeriChoice of New Jersey, AmeriChoice of New Jersey serves approx. 275,610 Medicaid and NJ Familycare members in the state. The health plan is a unit of AmeriChoice, the public sector health care business of UnitedHealth Group (NYSE: UNH). UnitedHealth Group is a diversified Fortune 50 health and well-being company. AmeriChoice serves 2.6 million people in more than 20 states and the District of Columbia. CEO of AmeriChoice Health Bolts. John J. Kirchner - Director, Operations John Kirchner joined Healthfirst in May 2010 with over 25 years experience in health care management. Mr. Kirchner’s background includes responsibility for health plan P&L, strategic planning and operations, and government and regulatory affairs. Mr. Kirchner will be responsible for supporting all aspects of NJ health plan operations. Prior to joining Healthfirst, Mr. Kirchner held a variety of positions at AmeriChoice of New Jersey serving as President from 2007 through 2009. Judical decision, It’s true there is email thanking AmeriChoice health for their $25,000 cash gift and requesting much larger amounts for the pending year etc. from Community Health Center located in Bridgeton N.J.etc. It’s also true a licensed Health agents was fired for his refusal to deliver these checks. It’s true this behavior violates all the laws concerning bribes, kickbacks,fraud and Stark laws. It’s true this taint’s all the business then received from Community health center to AmeriChoice Health Company and then submitted to Mediciad and should be then held accountable and subject to all violations. Among its provisions, the anti-kickback statute penalizes anyone who knowingly and willfully solicits, receives, offers or pays remuneration in cash or in kind to induce, or in return for: A. Referring an individual to a person for the furnishing, or arranging for the furnishing, of any item or service payable under the Medicare or Medicaid program; or B. Purchasing, leasing or ordering , or arranging for or recommending purchasing, leasing or ordering, any goods, facility, service or item payable under the Medicare or Medicaid program. Violators are subject to criminal penalties, or exclusion from participation in the Medicare and Medicaid programs, or both. A violation of the anti-kickback law is a felony offense that carries criminal fines of up to $25,000 per violation, imprisonment for up to five years and exclusion from government health care programs. The federal anti-kickback statute, 42 U.S.C.§ 1320a-7b(b), prohibits individuals or entities from knowingly and willfully offering, paying, soliciting or receiving remuneration to induce referrals of items or services covered by Medicare, Medicaid or any other federally funded program. For purposes of the anti-kickback statute,remuneration means or includes the transfer of anything of value, directly or indirectly, overtly or covertly, in cash or in-kind. ps Wonder how many other cash checks were disbursed to community centers by AmeriChoice Health guess only the Shadow knows the DOJ certainly does not. Don't you just love the words partner, collaborate, team player and yes, these words should be made trigger words for someone or something getting screwed.
Comment by More Medicaid Bribes
On behalf of AmeriChoice of Pennsylvania, I would like to welcome you as a participating provider in our Medicaid and Children’s Health Insurance Program (CHIP) products. We are committed to working with you and your staff to achieve the best possible outcomes for our members. This welcome kit contains valuable information about important contacts, policies, procedures and services to help you to conduct business with us as efficiently as possible. For easy navigation through the kit components, you can click on each link in the Table of Contents, which will bring you directly to that section. You can also download the Physician, Health Care Professional, Facility and Ancillary Administrative Guide by logging on to www.americhoice.com . This is a comprehensive reference source for the information you and your staff need regarding claims, benefits, prior authorization, medical management and other plan components. Again, we are pleased that you are one of our participating providers delivering quality care to our members. If you have any questions about your participation with AmeriChoice, or need a printed copy of this welcome kit, please call the Provider Service Helpline at 1-800-345-3627.
Sincerely,
Ernest Monfiletto Pennsylvania-East, Chief Executive Officer AmeriChoice of Pennsylvania AmeriChoice Provider Welcome Kit
This chart identifies bonus payments available to you, in addition to your regular payments, for compliance with HEDIS measures as defined by the National Committee for Quality Assurance (NCQA). For more information, call Jessica Anglin at 215-832-4590.
AmeriChoice Provider Welcome Kit This chart identifies bonus payments available to you, in addition to your regular payments, for compliance with HEDIS measures as defined by the National Committee for Quality Assurance (NCQA). For more information, call Jessica Anglin at 215-832-4590. Provider Incentives Measure Requirements AmeriChoice Will Available Referrals Adolescent Well-Care • Provider Incentive
AmeriChoice Provider Welcome Kit PaYour text goes here
Measure Requirements AmeriChoice Will Available Referrals Breast Cancer • Member Incentive: $50 VISA gift card Mammogram Females, Ages 40-69 years • Call members • Mail reminders • Offer auto messaging for providers • Assist in locating providers and scheduling appointments • Assist with ransportation QM Coordinator 215-832-4524 Case Management 877-651-6667 Cervical Cancer Screening (PAP) • Member Incentive: $25 VISA gift card Females, Ages 21-64 years • Call members • Mail reminders • Offer auto messaging for providers • Assist in locating providers and scheduling appointments • Assist with transportation QM Coordinator 215-832-4524 (to help schedule) Case Management 877-651-6667 Diabetes Care Provider Incentive: • Phase 1: Completed E and M visit ($100.00) and completed Cholesterol and HbA1C Screening • Phase 2: Diabetes managed – ($150.00); Cholesterol below 100 mg; HbA1c below 9 Ages 18-75 • HbA1C testing and documentation <9 • LDL screening and documentation <100 mg/dL) • Retinal eye exam performed • Blood pressure control • (<140/90 mm Hg) • Nephropathy screening test Urine macroalbumin □ Visit to nephrologist □ Treatment for nephropathy □ Therapy with ACE inhibitor/ARBs • Call members • Mail reminders • Provide Case Management • Offer auto messaging for providers Case Management 877-651-6667 Frequency of Ongoing Prenatal Care • Provider ncentive: $250 for completed prenatal intake form • Submission of completed prenatal intake form by provider • FAX to AmeriChoice HFS at 215-832-4986 • Provide Case Management Healthy First Steps (HFS) 877-651-6667 ER Diversion • Decrease overutilization of ER services for non-urgent diagnosis • Call members • Provide Case Management Case Management 877-651-6667
Comment by Can you feel the Love
An investigation begun by New York’s Attorney General, Andrew Cuomo said the company Ingenix, a research firm owned by UnitedHealth Group deliberately shorted reimbursements on out-of-network health insurance claims for Americans to the tune of hundreds of millions of dollars! Ingenix claimed it relied on ‘independent research from across the health care industry’ to determine reimbursement rates. However, UnitedHealth Group and its company Ingenix manipulated the health care claims presented by millions of Americans having health insurance and shorted their reimbursements between 10% and 28% of what the coverage should have paid. Instead, UnitedHealth Group, pocketed the millions of dollars it shorted Americans. UnitedHealth Group provides health benefits to 26 million Americans. Nearly all health care insurance companies in the country were using the same low reimbursement rates. Some of the largest health insurance companies who utilize the same Ingenix system are United Health Care (owned by UnitedHealth Group), Aetna, Cigna, Wellpoint/Empire BlueCross BlueShield and Genix. These companies are currently under investigation in New York suspected of participating in the same reimbursement fraud. How ironic UnitedHealth Group’s mission statement says in part: “We seek to enhance the performance of the health system and improve the overall health and well-being of the people we serve…We work with health care professionals to expand access to high-quality health care so people get the care they need at an affordable price.” Rather than anyone going to jail, UnitedHealth Group settled with the New York Attorney General by agreeing to pay $50 Million as the settlement to be used to establish and create a new database to determine rates for patients who choose physicians outside of the insurance giant’s network. Little good this does for the millions of Americans who were ripped off by these insurance scumbags. “This is a huge scam that affected hundreds of millions of Americans [who were] ripped off by their health insurance companies,” says Cuomo. “This was unethical, and it robbed vulnerable patients of insurance reimbursements they deserved.” Cuomo is now investigating other insurance companies that use Ingenix’s database. There may be millions more on the line as well. Of course, as is the corporate way of the guilty, UnitedHealth Group stated “We respectfully disagree with the New York Attorney General’s findings that we manipulated data … (or that our ownership of Ingenix was a conflict of interest.) We agreed to his settlement because it was an effective way to address any perceived conflict of interest.” The American Medical Association, represented by Dr. Nancy Nielson, president-elect of the AMA stated “there is a profit motive for keeping reimbursement low.” ”It is shocking and unacceptable for an insurance company to hide behind a shroud of secrecy”. Nielson also said “It is another example of UnitedHealth playing by its own rules.” This is not the first time UnitedHealth has been involved in legal action. In 2000, the AMA filed a lawsuit in federal court in New York over the exact same reimbursement issues. In May of 2008, Oxford Health Insurance, Inc, a unit of UnitedHealth Group, had to refund $50 million to small business customers in New York to settle claims it overcharged for health insurance policies back in 2006. More trouble from the past, when former CEO, William W. McGuire, M.D. was charged with securities fraud by the SEC. Mr. McGuire ultimately found guilty, had to repay $468 million as a partial settlement of the prosecution. In summary, I am of the opinion that corporate America is as corrupt as anywhere on earth. CEO bilking millions in golden parachutes and executive compensation, while American citizens fund their luxurious lifestyles with hard earn money, simply to be overcharged, cheated and ripped off by the rich and powerful. The UnitedHealth Group scam, is no different that the crooks on Wall Street: AIG, Goldman Sachs, Morgan Stanley, Merrill Lynch, Lehman Brothers, Bear Stearns, Fannie Mae, Freddie Mac, Citigroup, and other corporate manipulators such as Shell Oil, Exxon-Mobile, and so many other financial and energy leading companies. The free market system is over in America, thanks to corporate greed which took its roots during the Reagan trickledown economic philosophy. Corporate America cannot and should not be trusted and the federal government is almost in the same boat. Disdain for hardworking Americans by the Wall Street and Corporate America is so prevalent, they no longer tried to hide. The ‘haves’ continues to increase the divide between the ‘have not’s. Americans, Republicans and Democrats, should be outraged and the raping and pillaging of their money by Corporate America. We must begin to demand a government that works with incorporating fines and bringing to justice those criminals who rob, steal and cheap on a national basis from hard working citizens. None of the men leading these companies have gone to jail. Where is the justice for middle American who pays the bills for these outlaws?