"Dr. Michael Reilly's lawyer gave his client strong advice after reviewing a lucrative employment contract that the North Broward Hospital District offered him 15 years ago.
“I should throw this in the trash,” Reilly, a now-retired orthopedic surgeon, recalls the attorney telling him.
The contract, the lawyer said, had major problems, including that it violated the federal Stark law, which bars physicians from referring Medicare patients to hospitals, labs and other doctors that the physicians have financial relationships with unless they fall under certain circumstances.
Reilly didn't sign the contract.
That moment marked the beginning of Reilly's quest to hold North Broward Hospital District—a taxing district that operates five hospitals in Broward County in South Florida—accountable for alleged violations of the law. Reilly later filed a whistle-blower lawsuit against North Broward under the False Claims Act. In September, North Broward and the government settled the case for $69.5 million, with Reilly getting $12 million. North Broward did not admit to any wrongdoing. It declined to comment for this article.
Both plaintiff and defense attorneys predict that more False Claims Act cases alleging Stark violations are on the way, with whistle-blowers largely driving the U.S. Justice Department's enforcement—exponentially multiplying the government's regulatory eyes inside healthcare facilities. That's partly because two giant cases, involving Tuomey Healthcare System and Halifax Health, alerted potential whistle-blowers inside hospitals to the riches they could pocket by bringing such cases, some attorneys say.
In October, Tuomey in Sumter, S.C., agreed to settle with the government for $72.4 million, resolving allegations that it paid doctors in ways that rewarded them for referring patients to the hospital. Last year, Halifax in Daytona Beach, Fla., agreed to pay $85 million to settle allegations that it also had compensated physicians in illegal ways. Halifax did not admit to any wrongdoing. The whistle-blower in the Tuomey case got $18.1 million, while the whistle-blower in the Halifax case bagged $20.8 million."
Read more at Modern Healthcare
"The CMS has revealed that it underpays health plans that enroll large numbers of people who are dually eligible for Medicare and Medicaid, and the agency plans to modify its risk-adjustment model to make up for the underpayment.
In response to persistent and vocal complaints from health plans questioning the accuracy of the CMS' model for predicting costs of dual-eligible beneficiaries, the agency conducted a retrospective analysis of its 2014 plan data.
The CMS uses a prospective model (called the CMS-HCC) to calculate risk scores, using health status in a base year to predict costs in the following year. Those scores drive adjustments to capitated payments made for elderly and disabled beneficiaries enrolled in Medicare Advantage (MA) plans and certain demonstration programs.
“Our findings show that the community segment of the 2014 model … somewhat underpredicts for full-benefit, dual-eligible beneficiaries,” the CMS said in an under-the-radar notice sent to plans on Oct. 28. The agency did not reveal a dollar amount for the underpayment.
In the highly technical document, the agency outlined some tweaks to its risk model that officials believe will lead to more accurate payments to plans. The CMS is seeking comments on the proposed alterations by Nov. 25, and will publish final changes in a notice for the following payment year in February 2016."
Read more at Modern Healthcare
"California regulators fined two insurance giants for overstating their Obamacare doctor networks and said the companies will pay millions of dollars in refunds to patients who paid too much for care.
The state’s Department of Managed Health Care levied fines of $350,000 against Blue Shield of California and $250,000 for Anthem Blue Cross.
At issue were the companies’ error-riddled provider directories that frustrated many consumers statewide as they tried to find doctors during the rollout of the Affordable Care Act in 2014. As a result, some patients incurred big unforeseen medical bills because they unwittingly went out of network for care.
In addition to the state's enforcement action, consumer lawsuits are still pending against both insurers."
Read more at LA Times
More than 450 hospitals, including 27 in California pay over $250 million in cardiac-device investigation
"More than 450 hospitals have settled with the government for more than $250 million as part of a yearslong, nationwide investigation into the suspected overuse of implantable cardiac devices, the U.S. Justice Department announced Friday.
The hospital systems involved include many of the country's largest, such as Adventist, Ascension Health, Banner Health, Catholic Health Initiatives, Community Health Systems, HCA, Tenet Healthcare Corp. and Universal Health Services among others.
At 42, HCA had the most hospitals involved in settlements and is paying the highest portion of the settlement, $15.8 million, followed by Ascension Health with 32 settling for $14.9 million and then Community Health Systems with 31 settling for $13 million.
None of those three systems admitted to any liability as part of their settlements.
Community Health Systems said in a statement Friday it agreed to the settlement to “avoid the continuing delay, uncertainty, inconvenience and expense of protracted litigation.”
“The issue involved a highly technical interpretation of a Medicare national coverage determination that was the subject of strong disagreement in the medical community," Community Health Systems said.
Ascension spokesman Nick Ragone said in a statement that Ascension was pleased to have reached an agreement with the Justice Department. “We are proud and appreciative of the cardiac care provided by our physicians, nurses and other caregivers nationwide to individuals in the communities we serve,” Ragone said."
Read more a Modern Healthcare