DOJ still aggressively pursuing unnecessary therapy

FOR IMMEDIATE RELEASE

Thursday, October 29, 2015

Government Intervenes in Lawsuits Alleging That Skilled Nursing Chain SavaSeniorCare Provided Medically Unnecessary Therapy

The government has intervened in three False Claims Act lawsuits and filed a consolidated complaint against SavaSeniorCare LLC and related entities (Sava) alleging that Sava knowingly and routinely submitted false claims to Medicare for rehabilitation therapy services that were not medically reasonable and necessary, the Department of Justice announced today.  Sava is one of the nation's largest healthcare providers, operating approximately 200 skilled nursing facilities (SNFs) in 23 states.

"The provision of Medicare benefits must be dictated by patient need, not by Medicare providers' efforts to maximize profits by pressuring their employees to provide medically unnecessary services," said Principal Deputy Assistant Attorney General Benjamin C. Mizer of the Justice Department's Civil Division.  "The Department of Justice will continue to aggressively pursue companies that seek to engage in this kind of fraudulent scheme."

The government's complaint alleges that Sava exerted significant pressure on its SNFs to meet unrealistic financial goals that resulted in the provision of medically unreasonable, unnecessary and unskilled services to Medicare patients.  Sava allegedly set these aggressive, prospective corporate targets for the highest Medicare reimbursement rates to significantly increase Sava's revenues without regard for its patients' actual clinical needs and then pressured its staff to meet those goals.  Sava also allegedly delayed discharging patients from its facilities, even though the patients were medically ready to be discharged, in order to increase its Medicare payments.

"Enforcing the False Claims Act and combating healthcare fraud remains a top priority of the U.S. Attorney's Office," said U.S. Attorney David Rivera of the Middle District of Tennessee.  "When healthcare providers subject patients to unnecessary treatment, we will intervene and hold them accountable."

The three consolidated lawsuits were filed under the qui tam, or whistleblower, provisions of the False Claims Act, which permit private parties to sue on behalf of the government for false claims for government funds and to receive a share of any recovery.  The False Claims Act also permits the government to intervene in such lawsuits, as it has done in these cases.  Under the Act, a defendant that is found liable is subject to damages equal to three times the government's loss plus applicable penalties. 

The government's intervention in these matters illustrates its emphasis on combating health care fraud and marks another achievement for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced in May 2009 by the Attorney General and the Secretary of Health and Human Services.  The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation.  One of the most powerful tools in this effort is the False Claims Act.  Since January 2009, the Justice Department has recovered a total of more than $26.2 billion through False Claims Act cases, with more than $16.4 billion of that amount recovered in cases involving fraud against federal health care programs.  Tips and complaints from all sources about potential fraud, waste, abuse and mismanagement, including the conduct described in the United States' complaint, can be reported to the Department of Health and Human Services at 800-HHS-TIPS (800-447-8477).

The lawsuits are being handled by the Civil Division's Commercial Litigation Branch and the U.S. Attorney's Office of the Middle District of Tennessee.  Investigative support is being provided by the U.S. Attorneys' Offices of the Southern District of Texas and the Western District of Texas; the Offices of Inspector General for the Department of Health and Human Services and the Office of Personnel Management and the National Association of Medicaid Fraud Control Units.

The cases are captioned United States ex rel. Hayward v. SavaSeniorCare, LLC, et al., No. 3:11-0821 (M.D. Tenn.);United States ex rel. Scott v. SavaSeniorCare Administrative Services, LLC, 3:15-0404 (M.D. Tenn.); and United States ex rel. Kukoyi v. Sava Senior Care, L.L.C., et al., No. 3:15-1102 (M.D. Tenn.).

The claims asserted in the government's complaint against Sava are allegations only and there has been no determination of liability.

From http://www.justice.gov/opa/pr/government-intervenes-lawsuits-alleging-skilled-nursing-chain-savaseniorcare-provided

CMS Extends Deadline to submit ADR packets

SUBJECT: Pub. 100-08 Chapter 3 Updates: Section 3.2.3.2 Timeframes for Submission and Section 3.2.3.8 - No response to Additional Documentation Requests 

SUMMARY OF CHANGES: The purpose of this change request (CR) is to extend the due date for submitted documentation from providers, requested by the Medicare Administrative Contractors (MACs), Comprehensive Error Rate Testing (CERT) and Recovery Auditors in chapter 3 of Pub. 100-08, sections 3.2.3.2-Timeframes for Submission and 3.2.3.8 - No response to Additional Documentation Requests. 

EFFECTIVE DATE: November 17, 2015 *Unless otherwise specified, the effective date is the date of service. IMPLEMENTATION DATE: November 17, 2015

Requirements:

·         When requesting documentation for post payment review, the MAC, CERT and Recovery Auditors shall notify providers that the requested documents are to be submitted within 45 calendar days of the request

·         MACs and CERT, shall grant at least one extension to providers who need more time to comply with the request.

More information:

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R620PI.pdf

AMDA makes it's newsletter available for free to anyone. Link to sign up in this blog post

Caring for the Ages Editor-in-Chief Karl Steinberg, MD, CMD, takes great pride in the publication. "There is something for everyone in it. Every month, we make sure it is chock full of practical ideas and information, nuts and bolts of policy issues and regulatory news, research and drug news, and turnkey type tips and protocols that you can take and put in your arsenal of tools," he says.

"We're thrilled to make Caring available online to a broader audience. I encourage all AMDA members to recommend this opportunity to their colleagues, including physicians, administrators, front-line staff, nurses, and others," he says.

This is a scroll box. Click it and scroll down to get the link to sign up for the free newsletter  in the last line of this scroll box.

“We’re thrilled to make Caring available online to a broader audience. I encourage all AMDA members to recommend this opportunity to their colleagues, including physicians, administrators, front-line staff, nurses, and others,” he says. “We will not share their email addresses or contact information with anyone—it will be completely private; and they can un-subscribe at any time.”

Dr. Steinberg takes great pride in Caring. “There is something for everyone in it. Every month, we make sure it is chock full of practical ideas and information, nuts and bolts of policy issues and regulatory news, research and drug news, and turnkey type tips and protocols that you can take and put in your arsenal of tools.” The Caring for Consumers column, he further notes, is a great tool to share with family members and residents; and it is the perfect way to start conversations on a wide variety of issues.

For Caring readers and others, Dr. Steinberg is a familiar face and welcome presence. In addition to being an active medical director and attending physician in California and Editor-in-Chief of Caring, Dr. Steinberg is on the AMDA Board of Directors and chairs AMDA's Public Policy Committee, and he chairs the Coalition for Compassionate Care of California. His smiling face—as well as those of his dogs—can be seen in the pages of the annual AMDA Foundation Caring Canines calendar; in fact, in his facilities, his dogs are as well-known as he is (or more so, he says).

Dr. Steinberg isn’t just Editor of Caring. He also is a devoted reader. “I review every article that goes in and some that don’t. I really get a broad overview of what is happening, and I keep a finger on the pulse of new developments, trends, and studies. I also learn about the great things my colleagues are doing across the country.” 

Click here to sign up for your free Caring e-table of contents.

Virginia DMAS Emergency Preparations: From VHCA & DMAS

October 1, 2015

Dear Judy,

The Department of Medical Assistance Services (DMAS) asked VHCA to pass along the following information to members.   Due to the upcoming potential for inclement weather, DMAS has instituted the following emergency procedures:   1.  All pre-admission screening requirements are currently being waived for emergency admissions to the nursing facilities due to the potential for inclement weather.  The time frame covered for this waiver Friday, October 2, 2015 to Tuesday, October 6, 2015.  Any admission to nursing facilities during this time frame will be approved by DMAS provided documentation is given to support the emergency admission.  All documentation related to the emergency admission should be directed to Melissa Fritzman via fax at (804) 612-0040.  The documentation should include the completed PIRS form and information regarding the nature of the emergency admission.   2.  All emergency transportation needed to facilitate movement of individuals from their homes to a nursing facility and/or hospital will be reimbursed by DMAS.  Our transportation coordinator, LogistiCare, has been notified of DMAS' intent to honor all emergency transportation issues related to the facilitation of movement of these individuals to nursing facilities and/or hospital during the period of Friday, October 2, 2015 to Tuesday, October 6, 2015.  All transportation claims related to the movement of individuals to nursing facilities/hospitals in an emergency basis because of the inclement weather should be sent directly to Melissa Fritzman at the following address and should include clear documentation that of the nature of the transportation related to an emergency placement.     3.  Please contact LogistiCare at 1-866-679-6330 during the period of Friday, October 2, 2015 to Tuesday, October 6, 2015 for emergency placements ONLY.  This number will only be active during the time frame outlined above specifically for emergency placements ONLY.  The approvals will cover round trip transportation.     Send claims to:    Melissa Fritzman, Supervisor  Long-Term Care Division  Department of Medical Assistance Services  600 East Broad Street, Suite 1300  Richmond, Virginia 23219 If we receive any additional information or updates related to the forecasted severe weather, we will forward it to you.   Sincerely,   Keith Hare President and CEO VHCA / VCAL

Payroll Based Journal: Action Items from CMS - PBJ Voluntary sign up now, mandatory July 2016

Important PBJ Provider Action Items Step 1: Registration opened August 4th: Registration Training: - PBJ Training Modules for an introduction to the PBJ system and step by step registration instruction are available on QTSO e-University, select the PBJ option. (https://www.qtso.com/webex/qiesclasses.php) Registration: -Obtain a CMSNet User ID for PBJ Individual, Corporate and Third Party users, if you don't already have one for other QIES applications. (https://www.qtso.com/cmsnet.html) -Obtain a PBJ QIES Provider ID for CASPER Reporting and PBJ system access. You will need to be logged into your CMSNet account to access this page (https://mds.qiesnet.org/mds_home.html) -PBJ Corporate and Third-Parties must use the current form based process to register for a QIES ID. Registration forms are available under the Access Request Information / Forms section on the right side of the page. (https://www.qtso.com/) Step 2: Voluntary Data Submission will start October 1st: Data Submission Training: -PBJ Training Modules for the CASPER Reporting and PBJ systems will be available on September 25, 2015, on QTSO e-University, select the PBJ option. (https://www.qtso.com/webex/qiesclasses.php) -The CASPER Reporting and PBJ systems will be available on October 1, 2015. A user will be able to submit XML files or manually enter staffing and census data for work performed on or after October 1, 2015. (https://mds.qiesnet.org/mds_home.html) Other Resources: -Staffing Data Submission - PBJ Website: (http://www.cms.gov/Medicare/Quality-Initiatives- Patient-Assessment-Instruments/NursingHomeQualityInits/Staffing-Data-Submission-PBJ.html) -We will communicate information about PBJ through the Skilled Nursing Facilities/Long-Term Care Open Door Forum. More information can be found at https://www.cms.gov/Outreach-and- Education/Outreach/OpenDoorForums/ODF_SNFLTC.html. MAXIMUM NUMBER OF QIES USER IDs ALLOWED Nursing home individual providers are allowed a maximum of two (2) users with Access Type = PBJ An existing MDS user may request PBJ access be added to their existing QIES (MDS) ID if they will be responsible for submitting PBJ data or A new user may register for a QIES (PBJ) ID that allows access to only the PBJ application Exceptions to these limitations may be requested and granted, if approved. If the maximum number of individual QIES user IDs is already associated with your provider, an error message will display “The max number of users has been reached for the provider”. Providers requiring more than the prescribed maximum number of active individual QIES user IDs must complete and submit an “Individual User Account Request” form to request additional IDs. This form is available at https://www.qtso.com/accesspbj.html Please Note: PBJ Corporate and PBJ Third Party Service Bureaus do not have a limit on the number of active users with Access Type = PBJ. PBJ Corporate and PBJ Third Party Service Bureaus will register/update their QIES User ID using the current form based process. These forms are located at https://www.qtso.com/accesspbj.html A list of important action items for PBJ Providers is available for download. Important PBJ Provider Action Items [PDF 31 KB] From https://www.qtso.com/providernh.html