Part of the Bay Area News Group

Stark and Herger pitch Medicare fraud bill

By Josh Richman
Wednesday, September 15th, 2010 at 1:38 pm in Pete Stark, U.S. House.

Lest anyone think there’s no bipartisanship whatsoever in Washington these days, Rep. Pete Stark, D-Fremont, and Rep. Wally Herger, R-Chico, today introduced a bill together to fight Medicare fraud.

H.R. 6130, the Strengthening Medicare Anti-Fraud Measures Act, would expand the authority of the Heath and Human Services Office of Inspector General (OIG) to let it ban corporate executives from doing business with Medicare if their companies were convicted of fraud. It also gives the OIG the ability to exclude parent companies that may be committing fraud through shell companies. The OIG’s chief counsel asked members of the House Ways and Means Committee for these changes at a June hearing on Medicare fraud.

Pete Stark“This legislation gives the Office of Inspector General the authority to go after crooked executives and corporations that continue to bilk Medicare,” Stark, chairman of the Ways and Means Health Subcommittee, said in a news release. “Stopping these swindlers will save taxpayer money and protect Medicare beneficiaries. I appreciate the OIG making this request for more authority, and thank my Democratic and Republican colleagues, especially Mr. Herger, for working together to address this issue.”

Herger, the subcommittee’s ranking Republican, called Medicare fraud “a crime against senior citizens, legitimate health care providers, and every American who pays taxes.

Wally Herger“It is imperative for us to remain vigilant to prevent Medicare fraud, and to ensure that those who do commit fraud don’t get a second chance at their crimes,” he said. “With Medicare already on an unsustainable fiscal path, it is inexcusable to allow more and more taxpayer dollars to be defrauded. Law enforcement officials have informed Congress that there are gaps in our current anti-fraud laws, and I am pleased to join Chairman Stark in offering legislation to close the loopholes so that these offenders will pay the price for their crimes.”

Besides Stark and Herger, the bill’s 17 other original cosponsors include six Republicans and 11 Democrats.

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  • Common Tater

    Pete Stark would certainly be the person I would pick who knows most about fraud…

  • Sounds Great

    The Players and whats up for grabs. Profits United Health Group 2010 $4.293 billion
    Here are some other 2010 budget numbers: Wonder what it cost CMS ( Can’t Manage Shit) to operate each year. $453 billion Medicare/// $290 billion Medicaid ///$78.7 billion Department of Health and Human Services/// UnitedHealth Group Awarded TRICARE Managed Care Support Contract … Jul 13, 2009 … UnitedHealth Group Awarded TRICARE Managed Care Support Contract for more than $20.3 billion. BILLIONS awarded and still to be awarded 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% last year, to $6 billion.

    United Health Group and its subsidiarys must be exhausted from signing Corporate Integrity agreements each and every year and as reward for their violations well what happens? they are awarded more contracts and more money and maybe even an ambassadorship here and there and if anybody should question what the heck is going on, then send them a Elmo doll. (Americhoice sponsors Sesame Street) Up side, Billions to be made, down side pay some fines (cost of doing business) move on and nobody goes to jail or gets excluded from the game. Get up the next day put on your Elmo costume and its back to work as usual. WOW, even in the Casino world or Mob world this would be a no no, suprised Hollywood has not done a movie on this or maybe even great TV.
    Full Name: Wayne Berman Title: Vice-Chair; Finance Co-Chair; Adviser

    Over the course of three years, Berman’s lobbying firm was paid $660,000 to lobby on behalf of UnitedHealth subsidiary Americhoice, a managed care HMO providing health insurance to Medicaid, Medicare, and SCHIP recipients. Specifically, according to the lobbying report, they lobbied on Medicaid issues in the Deficit Reduction Act of 2005. [Americhoice Lobbying Reports 2004 – 2007; Americhoice.com] Berman Also Lobbied For “Absurdly Low” Rates for Medicaid Managed Care Companies to Pay Out of Network Hospitals. Also included in the DRA, and mentioned as a lobbying issue on Berman’s Americhoice lobbying report, was a provision setting rates managed care companies must pay to out-of-network providers — mainly hospital emergency rooms — for care received by Medicaid beneficiaries. Rather than forcing managed care companies to reimburse out-of-network hospitals an amount comparable to network providers, the legislation set the default amount to the state’s “fee-for-service rate,” which often is “absurdly low.” The provision thereby shifted financial responsibility for services to Medicaid beneficiaries from the managed care companies to the hospitals themselves, permitting managed care companies to rake in huge profits, while hospitals incurred added losses. [Modern Healthcare, 1/29/07; Text of S. 1932] To Save Money, Bill Cut Services to Medicaid Beneficiaries, But Left Managed Care Providers Untouched. Under the final budget package, substantial Medicaid spending cuts were achieved by imposing new premiums and increased co-payments on Medicaid beneficiaries; some costs were also shifted to the states, who in return were awarded new powers to drop coverage or reduce benefits to certain beneficiaries. In a letter to Senate Majority Leader Bill Frist, the AARP CEO decried the final bill, saying it “protects the pharmaceutical industry, the managed-care industry and other providers at the expense of low-income Medicaid beneficiaries.” [Inside CMS, 12/29/05; Los Angeles Times, 12/22/05; World Markets Analysis, 12/21/05; The Hill, 12/20/05]

  • More Required

    The government can’t see the conflict of interest its created with AmeriChoice Heath. This company receives all its money from Federal and State governments yet derives its profits from who how they administer their responsibility for these programs.This company is left unchecked year after year and their profits and power keep increasing because they think they are above the Federal and State laws. A FEDERAL JUDGE SAYS IF THEY DID NOT PROMISE OR SIGN ANYTHING, HEY, KICKBACKS ARE OK!! WHICH IS NOT TRUE BY THE WAY. 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. 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.

    The way this Judge thinks one would have to work in the billing department in order to prevail. Since when do you have to certify complaince not to break Federal and State kickbacks laws?

  • Rick K.

    Re: crackdown on Medicare fraud bill. Why wasn’t this a part of the massive 2010 health care reform law? Why wasn’t this addressed years ago? Think of how many millions of dollars have been wasted through fraud while Congress ignores this problem. A major reason why Republicans lost control of the House in 2006 and Democrats are danger of losing control after just four years is that no party seems interested in actually dealing with the day-to-day, “nut and bolts” business of the legislative branch. They’re too busy passing useless resolutions naming post offices after each other. I’m in favor of fewer partisan press conferences and more oversight hearings on Capitol Hill.

  • Medicaid POT Beneficiaries

    14,000 New Yorkers double-dip into ‘Medicaid Pot” BY Kenneth Lovett DAILY NEWS ALBANY BUREAU CHIEF Wednesday, March 4th 2009, 12:14 AM ALBANY – Nearly 14,000 Medicaid recipients in New York City are double-dipping in other states, a new report found. Florida, Puerto Rico and New Jersey had the most Medicaid recipients also enrolled in New York, an audit by state Controller Thomas DiNapoli’s office revealed. The dual enrollments cost the federal, state and city governments a combined $23.5 million in Medicaid claims from April 2004 through May 2008, the audit found. While some of the claims were legitimate, DiNapoli suspects many were not. In some cases, people may have illegally used the Medicaid program in each state they were enrolled. In others, New York’s more generous program might have covered costs that should have been paid for by other states, DiNapoli said. The city Human Resources Administration has not completed investigations of $11.1 million in possible inappropriate Medicaid managed care premium payments, the audit found. While the enrollees may have been getting services they were not entitled to in New York, the medical providers got the money, DiNapoli said. “The state is facing the worst fiscal crisis of our lifetime,” DiNapoli said. “We can’t afford to waste millions of dollars on people who don’t live here.” The controller said the state Department of Health

    Election Year Medicaid Medicare Inducement issues left open for November not openly discussed.Politics have gone from heated to man on fire thoughts. Also the Judicial dilemmas, since all are offically allowed to bear arms again, the big city Mayors are concerned about how the poor will be able to rearm themselves, and are looking for some type of financial relief from Federal State Medicaid programs to maintain their status quo.The higher courts face tough issues this term since making honest fraud legal, there agenda now turns toward making honest kickbacks and honest bribes equally as legal. This topic remains high as a shared issue by the medicaid medicare enrollment providers since they are looking to expand inducements past the complicated pregnancy stage.

    The DOJ has serious concerns that if legalized marijuana in California for medical reasons could be used as a inducement or inticement to help secure new enrollments for the Federal State Medicare Medicaid programs.The State of California is concerned that if the Feds step up their effort in killing off the marijuana crops it could cause higher tax problems that effect Medicaid currently under consideration by the State ‘marijuana tax control board’. Limo drivers cancel their planned Medicaid Cuts DC rally and leave for California to protect this years crop. Wow, don’t think I would like to be in Politics for this years elections. Govenor Schwarzenegger indicated that if the Tea Partys membership keeps holding their rallies at our Marijuana burning fields they will have to be taxed for their free use of inhalants, prior to having them bused back to Arizona. Senator Mccain wants the deportation of illegal Mexicans to stop immediatley claims their State has gone to POT and insists California return his landscapers at once.