Medicare Compliance & Reimbursement

Plus: Clinicians receive long prison sentences for Medicare fraud.

CMS began its Medicare card revamp in April, sending out replacement cards with new Medicare Beneficiary Identifiers (MBIs). However, despite being only six months into the new program and on the heels of the Wave 7 release, the HHS Office of Inspector General (OIG) has already added MBI-laden cards to its work plan.

Why? CMS commenced the new initiative to replace Social Security number-based Health Insurance Claim Number (HICN) with the new alpha-numeric MBIs to combat identity theft. The rollout started in April of 2018, and the agency hopes all beneficiaries will have cards in hand by April 2019. The transition period for providers to have all systems and protocols in line with the new MBI requirements ends January 2020.

Wave update: If you practice in a Wave 7 state or territory — Kentucky, Louisiana, Michigan, Mississippi, Missouri, Ohio, Puerto Rico, Tennessee, and the Virgin Islands — your patients should be on the lookout for their new Medicare cards. Wave 6 is still in process, but according to new reports from CMS, Waves 1 through 5 are now complete.

Review the newest MLN Connects on Wave 7 at www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2018-10-15-eNews-SE.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=descending.

Work plan: As CMS continues to clarify and clean up MBI problems, OIG is investigating issues. “We will conduct a series of reviews to assess controls in place to distribute and implement usage of the MBI,” noted an OIG work plan summary.

The agency hopes to “determine the number and nature of Medicare cards returned as undeliverable and the extent to which CMS tracks and follows up on Medicare cards returned as undeliverable,” but also to ensure “safeguards” are in place to protect beneficiaries, the work plan guidance said.

OIG will also home in on provider payments as the mailings continue, reviewing discrepancies. The work plan suggests that fraud is an issue with the use of MBIs “for inappropriate items and services” and the agency will be scrutinizing these payments, the summary showed.

Read the OIG work plan release at: https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000324.asp.

In other news…

A recent settlement shows that clinicians are increasingly being held accountable for false and fraudulent claims — that sometimes bring long prison sentences, too.

Through coordinated efforts in the Dallas area, a physician house-call company, Boomer House Calls (Boomer), and home health provider, Timely Home Health Services Inc. (Timely), sought to defraud Medicare. After a five-day trial, three nurses and two physicians were found guilty of a home health fraud scheme totalling over $11.3 million in false and fraudulent claims, noted a Department of Justice (DOJ) release on the case.

Timely co-owner, Patience Okoroji, LVN, received the heftiest prison sentence at 10 years while physician and Boomer co-owner, Kelly Robinett, MD, was sentenced 42 months jail time. Timely nurses, Joy Ogwuegbu, RN, and Kingsley Nwanguma, LVN, both garnered 3 years in prison. Angel Claudio, MD, was sentenced to six months. Timely co-owner, Usani Ewah, RN, and Boomer co-owner, Shawn Chamberlain, PA, await sentencing in the case.

Between 2007 and 2015, Boomer clinicians’ certified Medicare beneficiaries for treatment, but the patients were never cared for or even seen; the physicians then referred the beneficiaries to Timely for home health services that were then never provided, according to the DOJ report.

“The evidence presented at trial showed that Robinett, a doctor of osteopathic medicine, certified Medicare beneficiaries — whom he had never seen and did not care to see — for medically unnecessary home health services that were often not provided,” said the DOJ release. “The evidence further established that Ogwuegbu, a registered nurse, falsified nursing assessments and Nwanguma, a licensed vocational nurse, falsified nursing notes, to make it appear as if Medicare beneficiaries were qualified for and were provided skilled nursing services.”

See the details of the case at www.justice.gov/opa/pr/dallas-physicians-and-nurses-sentenced-prison-role-11-million-medicare-fraud-scheme.