March 4, 2012 — 2:35pm ET | By Dina Overland
Blue Shield of California is seeking $10.5 million in damages from Monarch HealthCare, claiming its contract was violated after rival insurer UnitedHealth purchased the large doctor group.
In its complaint announced Wednesday, Blue Shield of California said Monarch violated its contract by agreeing to be acquired without obtaining Blue Shield's consent, steering Blue Shield members toward rival health plans and declining to treat some Blue Shield members, reported The Wall Street Journal.
Blue Shield said 19,000 of its commercial and Medicare Advantage members were receiving care from Monarch in September when UnitedHealth's health services unit Optum bought the Orange County provider group. However, Blue Shield says it lost most of its 2,400 Medicare members and lost potential new enrollees because of Monarch's contract violations, the Los Angeles Times reported.
The complaint specifically claims that Monarch advertised to its Medicare members that they should switch health plans to keep their doctors, according to the Orange County Register. "There is an active recruitment of our members to UnitedHealth," said Juan Davila, Blue Shield's senior vice president for network management.
This situation highlights the increasingly common merger between insurers and providers and the tensions that often emerge, as a result. "This is certainly a sign of things to come as we enter one of the most significant restructurings of the healthcare market in years," Glenn Melnick, a health economist at Rand Corp., told the LA Times.
Read more: Blue Shield seeks $10.5M from rival UnitedHealth doc group - FierceHealthPayer http://www.fiercehealthpayer.com/story/blue-shield-seeks-105m-rival-unitedhealth-owned-doc-group/2012-03-04?utm_medium=nl&utm_source=internal?utm_source=AISHealth#ixzz1oLkfKG9t
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Tuesday, March 6, 2012
Blue Shield seeks $10.5M from rival UnitedHealth doc group
March 4, 2012 — 2:35pm ET | By Dina Overland
Blue Shield of California is seeking $10.5 million in damages from Monarch HealthCare, claiming its contract was violated after rival insurer UnitedHealth purchased the large doctor group.
In its complaint announced Wednesday, Blue Shield of California said Monarch violated its contract by agreeing to be acquired without obtaining Blue Shield's consent, steering Blue Shield members toward rival health plans and declining to treat some Blue Shield members, reported The Wall Street Journal.
Blue Shield said 19,000 of its commercial and Medicare Advantage members were receiving care from Monarch in September when UnitedHealth's health services unit Optum bought the Orange County provider group. However, Blue Shield says it lost most of its 2,400 Medicare members and lost potential new enrollees because of Monarch's contract violations, the Los Angeles Times reported.
The complaint specifically claims that Monarch advertised to its Medicare members that they should switch health plans to keep their doctors, according to the Orange County Register. "There is an active recruitment of our members to UnitedHealth," said Juan Davila, Blue Shield's senior vice president for network management.
This situation highlights the increasingly common merger between insurers and providers and the tensions that often emerge, as a result. "This is certainly a sign of things to come as we enter one of the most significant restructurings of the healthcare market in years," Glenn Melnick, a health economist at Rand Corp., told the LA Times.
Read more: Blue Shield seeks $10.5M from rival UnitedHealth doc group - FierceHealthPayer http://www.fiercehealthpayer.com/story/blue-shield-seeks-105m-rival-unitedhealth-owned-doc-group/2012-03-04?utm_medium=nl&utm_source=internal?utm_source=AISHealth#ixzz1oLkfKG9t
Blue Shield of California is seeking $10.5 million in damages from Monarch HealthCare, claiming its contract was violated after rival insurer UnitedHealth purchased the large doctor group.
In its complaint announced Wednesday, Blue Shield of California said Monarch violated its contract by agreeing to be acquired without obtaining Blue Shield's consent, steering Blue Shield members toward rival health plans and declining to treat some Blue Shield members, reported The Wall Street Journal.
Blue Shield said 19,000 of its commercial and Medicare Advantage members were receiving care from Monarch in September when UnitedHealth's health services unit Optum bought the Orange County provider group. However, Blue Shield says it lost most of its 2,400 Medicare members and lost potential new enrollees because of Monarch's contract violations, the Los Angeles Times reported.
The complaint specifically claims that Monarch advertised to its Medicare members that they should switch health plans to keep their doctors, according to the Orange County Register. "There is an active recruitment of our members to UnitedHealth," said Juan Davila, Blue Shield's senior vice president for network management.
This situation highlights the increasingly common merger between insurers and providers and the tensions that often emerge, as a result. "This is certainly a sign of things to come as we enter one of the most significant restructurings of the healthcare market in years," Glenn Melnick, a health economist at Rand Corp., told the LA Times.
Read more: Blue Shield seeks $10.5M from rival UnitedHealth doc group - FierceHealthPayer http://www.fiercehealthpayer.com/story/blue-shield-seeks-105m-rival-unitedhealth-owned-doc-group/2012-03-04?utm_medium=nl&utm_source=internal?utm_source=AISHealth#ixzz1oLkfKG9t
Monday, March 5, 2012
Only MLR Rebate Recipients Should Get Rebate Notices
By Allison Bell
MARCH 5, 2012
Keep it simple, CMS.
Daniel Durham, an executive vice president at America's Health Insurance Plans (AHIP), Washington, and Colleen Gallaher, a senior vice president at AHIP, make that case in a comment letter submitted to the Centers for Medicare & Medicaid Services (CMS).
CMS recently published a Federal Register notice seeking comments on the guidelines the agency ought to set for insurers and health plans that are sending notices regarding the rebates required by the minimum medical loss ratio (MLR) provisions created by Section 2718 of the Patient Protection and Affordable Care Act of 2010 (PPACA).
Durham and Gallaher write on behalf of AHIP that CMS officials ought to avoid any rules that could make complying with the MLR rebate notice requirements any more expensive or complicated than the statute requires.
"Imposing an additional, unnecessary administrative cost is flatly inconsistent with the purpose of the MLR provision," Durham and Gallaher say.
The PPACA MLR provisions require insurers to spend at least 85% of large group plan revenue and 80% of individual and small group plan revenue on health care and quality improvement efforts. Insurers that find health care and quality expenses fall below the minimum must provide rebates.
One way to simplify the rebate notice process is to drop a CMS proposal that calls for requiring notices to go to individuals who will not be receiving rebates, the AHIP executives say.
PPACA Section 2718 does not require health plans to distribute notices to enrollees in plans that have met the MLR threshold, the AHIP executives say.
Requiring plans to send notices to those enrollees would be duplicative, unnecessary, costly and confusing, and the costs would clearly outweigh any benefit, the AHIP executives say.
An executive order requires CMS to analyze whether the benefits of a rule will justify the costs, and CMS officials have not yet analyzed the effects of requiring rebate information notices to go to enrollees who will not be getting rebates, the AHIP executives say.
CMS officials have estimated that the burden of the regulation would be $71 million, but that estimation process is not a substitute for full analysis, the AHIP executives say.
In addition, CMS should avoid setting notice requirements that are too detailed, because PPACA Section 2718 does not actually require that any insurers send any MLR rebate notices, the AHIP executives say.
Instead of setting detailed requirements for the notices, CMS should provide sample notices and describe the performance objectives, rather than say how insurers must try to meet the objectives, the AHIP executives say.
CMS officials add that the proposed model notices CMS officials did provide are too hard for consumers to understand and do not meet the government's own Federal Plain Language Guidelines.
The AHIP executives also ask CMS to let an insurer send a rebate notice to the employer policyholder, then let the employer tell employees about the rebate.
Requiring health plans to issue rebates to the employer and then send notices to the employer plan enrollees would increase administrative costs for the employers and require the employers to take complicated steps to inform insurers about the whereabouts of employees, the AHIP executives say.
AHIP should issue rebate notice guidelines as quickly as possible, to give companies time to put the changes into effect, the AHIP executives say.
MARCH 5, 2012
Keep it simple, CMS.
Daniel Durham, an executive vice president at America's Health Insurance Plans (AHIP), Washington, and Colleen Gallaher, a senior vice president at AHIP, make that case in a comment letter submitted to the Centers for Medicare & Medicaid Services (CMS).
CMS recently published a Federal Register notice seeking comments on the guidelines the agency ought to set for insurers and health plans that are sending notices regarding the rebates required by the minimum medical loss ratio (MLR) provisions created by Section 2718 of the Patient Protection and Affordable Care Act of 2010 (PPACA).
Durham and Gallaher write on behalf of AHIP that CMS officials ought to avoid any rules that could make complying with the MLR rebate notice requirements any more expensive or complicated than the statute requires.
"Imposing an additional, unnecessary administrative cost is flatly inconsistent with the purpose of the MLR provision," Durham and Gallaher say.
The PPACA MLR provisions require insurers to spend at least 85% of large group plan revenue and 80% of individual and small group plan revenue on health care and quality improvement efforts. Insurers that find health care and quality expenses fall below the minimum must provide rebates.
One way to simplify the rebate notice process is to drop a CMS proposal that calls for requiring notices to go to individuals who will not be receiving rebates, the AHIP executives say.
PPACA Section 2718 does not require health plans to distribute notices to enrollees in plans that have met the MLR threshold, the AHIP executives say.
Requiring plans to send notices to those enrollees would be duplicative, unnecessary, costly and confusing, and the costs would clearly outweigh any benefit, the AHIP executives say.
An executive order requires CMS to analyze whether the benefits of a rule will justify the costs, and CMS officials have not yet analyzed the effects of requiring rebate information notices to go to enrollees who will not be getting rebates, the AHIP executives say.
CMS officials have estimated that the burden of the regulation would be $71 million, but that estimation process is not a substitute for full analysis, the AHIP executives say.
In addition, CMS should avoid setting notice requirements that are too detailed, because PPACA Section 2718 does not actually require that any insurers send any MLR rebate notices, the AHIP executives say.
Instead of setting detailed requirements for the notices, CMS should provide sample notices and describe the performance objectives, rather than say how insurers must try to meet the objectives, the AHIP executives say.
CMS officials add that the proposed model notices CMS officials did provide are too hard for consumers to understand and do not meet the government's own Federal Plain Language Guidelines.
The AHIP executives also ask CMS to let an insurer send a rebate notice to the employer policyholder, then let the employer tell employees about the rebate.
Requiring health plans to issue rebates to the employer and then send notices to the employer plan enrollees would increase administrative costs for the employers and require the employers to take complicated steps to inform insurers about the whereabouts of employees, the AHIP executives say.
AHIP should issue rebate notice guidelines as quickly as possible, to give companies time to put the changes into effect, the AHIP executives say.
Friday, March 2, 2012
Quote of the Day
“The widening of differential copays to incent the usage of both therapeutic and chemical equivalents is an effective method in driving utilization to generics and lowering costs, particularly in light of recent or anticipated generic releases that have been forecasted to represent approximately $35 billion in overall brand drug spend over the next year.”
— Allan Zimmerman, a director in the PricewaterhouseCoopers Human Resource Services practice, told AIS’s Drug Benefit News.
— Allan Zimmerman, a director in the PricewaterhouseCoopers Human Resource Services practice, told AIS’s Drug Benefit News.
Today's Datapoint
$5 billion … was cut from health reform’s prevention fund on Feb. 17 to help pay for the costs of blocking a 27% cut in Medicare physician payments.
Thursday, March 1, 2012
$375 MILLION HEALTH CARE FRAUD SCHEME
Office Manager for Doctor and Five Owners of Dallas-Area Home Health Agencies
Also Arrested
WASHINGTON - A physician and the office manager of his medical practice, along with five owners of home health agencies, were arrested today on charges related to their alleged participation in a nearly $375 million health care fraud scheme involving fraudulent claims for home health services.
The arrests and charges were announced today by Deputy Attorney General James Cole and Health and Human Services (HHS) Deputy Secretary Bill Corr, along with Assistant Attorney General Lanny A. Breuer of the Justice Department’s Criminal Division; U.S. Attorney Sarah R. Saldaña of the Northern District of Texas; HHS Inspector General Daniel R. Levinson; Special Agent in Charge Robert E. Casey Jr. of the FBI’s Dallas Field Office; Dr. Peter Budetti, Deputy Administrator for Program Integrity for the Centers for Medicare and Medicaid Services (CMS); and the Texas Attorney General’s Medicaid Fraud Control Unit (MFCU).
The indictment, filed in the Northern District of Texas and unsealed today, charges Jacques Roy, M.D., 54, of Rockwall, Texas; Cynthia Stiger, 49, of Dallas; Wilbert James Veasey Jr., 60, of Dallas; Cyprian Akamnonu, 63, of Cedar Hill, Texas; Patricia Akamnonu, RN, 48, of Cedar Hill; Teri Sivils, 44, of Midlothian, Texas; and Charity Eleda, RN, 51, of Rowlett, Texas, each with one count of conspiracy to commit health care fraud. Roy also is charged with nine counts of substantive health care fraud, and Veasey, Patricia Akamnonu and Eleda are each charged with three counts of health care fraud. Eleda also is charged with three counts of making false statements related to a Medicare claim. All the defendants are expected to make their initial appearances at 2:00 p.m. CST today in federal court in Dallas.
In addition to the indictment, CMS announced the suspension of an additional 78 home health agencies (HHA) associated with Roy based on credible allegations of fraud against them.
Today’s enforcement actions are the result of the Medicare Fraud Strike Force operations, which are part of the Health Care Fraud Prevention & Enforcement Action Team (HEAT). HEAT is a joint initiative announced in May 2009 between the Department of Justice and HHS to focus their efforts to prevent and deter fraud and enforce anti-fraud laws around the country.
“The conduct charged in this indictment represents the single largest fraud amount orchestrated by one doctor in the history of HEAT and our Medicare Fraud Strike Force operations,” said Deputy Attorney General Cole. “Thanks to the historic partnerships we’ve built to combat health care fraud, we are sending a clear message: If you victimize American taxpayers, we will track you down and prosecute you.”
“Thanks to our new fraud detection tools, we have greater abilities to identify the kind of sophisticated fraud scheme that previously could have escaped scrutiny,” said HHS Deputy Secretary Corr. “Our aggressive Medicare Fraud Strike Force operations have enabled us to break up a significant alleged fraud operation and the fraud-fighting authorities in the Affordable Care Act have allowed us to stop further payments to providers connected to this scheme. This case and our new detection tools are examples of our growing ability to stop Medicare fraud.”
According to the indictment, Dr. Roy owned and operated Medistat Group Associates P.A. in the Dallas area. Medistat was an association of health care providers that primarily provided home health certifications and performed patient home visits. Dr. Roy allegedly certified or directed the certification of more than 11,000 individual patients from more than 500 HHAs for home health services during the past five years. Between January 2006 and November 2011, Medistat certified more Medicare beneficiaries for home health services and had more purported patients than any other medical practice in the United States. These certifications allegedly resulted in more than $350 million being fraudulently billed to Medicare and more than $24 million being fraudulently billed to Medicaid by Medistat and HHAs.
“Today, the Medicare Fraud Strike Force is taking aim at the largest alleged home health fraud scheme ever committed,” said Assistant Attorney General Breuer. “According to the indictment, Dr. Roy and his co-conspirators, for years, ran a well-oiled fraudulent enterprise in the Dallas area, making millions by recruiting thousands of patients for unnecessary services, and billing Medicare for those services. In Dallas, and the eight other Medicare Fraud Strike Force cities, the Criminal Division and our partners in the U.S. Attorneys’ Offices will continue to crack down on Medicare fraud, and hold accountable those stealing from the public fisc.”
“Fraud schemes, like the one we allege Dr. Roy executed, represent the next wave of Medicare and Medicaid crime that we face,” said U.S. Attorney Saldaña. “As enforcement actions have ramped up, not only in the Dallas Metroplex, but in several other areas throughout the country, fraudsters are devising new ways to beat the system. Rest assured, however, that with the tools and resources our district’s Medicare Care Fraud Strike Force provides, we will meet this challenge head-on and bring indictments against those who seek to defraud these critical programs, and you, the taxpayer.”
“Using sophisticated data analysis we can now target suspicious billing spikes,” said HHS Inspector General Levinson. “In this case, our analysts discovered that in 2010, while 99 percent of physicians who certified patients for home health signed off on 104 or fewer people – Dr. Roy certified more than 5,000.”
“The FBI views health care fraud as a severe crime problem,” said FBI Special Agent in Charge Casey. “It causes increased costs for consumers, tax payers and health insurance plans, and degrades the integrity of our health care system and legitimate patient care. Today’s arrests by the Dallas Medicare Fraud Strike Force send a clear message to those persons who are not only defrauding our federal Medicare and Medicaid and private health insurance programs, but victimizing the elderly, the disadvantaged, and those who are at a vulnerable time in their lives due to legitimate health issues. The FBI will continue to dedicate a substantial amount of expert resources to investigate these crimes.”
The indictment alleges that Dr. Roy used HHAs as recruiters so that Medistat could bill unnecessary home visits and medical services. Dr. Roy and other Medistat physicians certified and recertified plans of care so that HHAs also were able to bill Medicare for home health services that were not medically necessary and not provided. In addition, Dr. Roy allegedly performed unnecessary home visits and ordered unnecessary medical services.
According to the indictment, Medistat maintained a “485 Department,” named for the number of the Medicare form on which the plan of care was documented. Dr. Roy allegedly instructed Medistat employees to complete the 485s by either signing his name by hand or by using his electronic signature on the document.
Three of the HHAs Dr. Roy used as part of the scheme were Apple of Your Eye Healthcare Services Inc., owned and operated by Stiger and Veasey; Ultimate Care Home Health Services Inc., owned and operated by Cyprian and Patricia Akamnonu; and Charry Home Care Services Inc., owned and operated by Eleda. According to the indictment, Veasey, Akamnonu, Eleda and others recruited beneficiaries to be placed at their HHAs so that they could bill Medicare for the unnecessary and not provided services. As part of her role in the scheme, Eleda allegedly visited The Bridge Homeless Shelter in Dallas to recruit homeless beneficiaries staying at the facility, paying recruiters $50 per beneficiary they found at The Bridge and directed to Eleda’s vehicle parked outside the shelter’s gates.
Apple allegedly submitted claims to Medicare from Jan. 1, 2006, through July 31, 2011, totaling $9,157,646 for home health services to Medicare beneficiaries that were medically unnecessary and not provided. Dr. Roy or another Medistat physician certified the services. From Jan. 1, 2006, to Aug. 31, 2011, Ultimate submitted claims for medically unnecessary home health services totaling $43,184,628. Charry allegedly submitted fraudulent claims from Aug. 1, 2008, to June 30, 2011, totaling $468,858 in medically unnecessary and not provided home health services.
The indictment alleges that Sivils, as Medistat’s office manager, helped facilitate the fraud scheme by, among other actions, supervising the processing of thousands of plans of care that contained Dr. Roy’s electronic signature and other Medistat physicians’ signatures, permitting HHAs to bill Medicare for unnecessary home health services and accepting cash payments from Cyprian Akamnonu in exchange for ensuring plans of care contained Dr. Roy or another Medistat physician’s signature.
As outlined in the government’s request to the court to detain Dr. Roy, in June 2011, CMS suspended provider numbers for Dr. Roy and Medistat based on credible allegations of fraud, thus ensuring Dr. Roy did not receive payment from Medicare. Immediately after the suspension, nearly all of Medistat’s employees started billing Medicare under the provider number for Medcare HouseCalls. The court document alleges that Dr. Roy was in fact in charge of day-to-day operations at Medcare, and that Dr. Roy continued to certify patients for home health despite the suspension.
Each charged count of conspiracy to commit health care fraud and substantive health care fraud carries a maximum penalty of 10 years in prison and a $250,000 fine. Each false statement charge carries a maximum penalty of five years in prison and a $250,000 fine. The indictment also seeks forfeiture of numerous items including funds in bank accounts, a sailboat, vehicles and multiple pieces of property.
An indictment is merely an allegation and defendants are presumed innocent unless and until proven guilty beyond a reasonable doubt in a court of law.
The case is being prosecuted by Assistant U.S. Attorneys Michael C. Elliott, Mindy Sauter and John DeLaGarza of the Northern District of Texas and Trial Attorney Ben O’Neil and Deputy Chief Sam S. Sheldon of the Criminal Division’s Fraud Section. The case was investigated by the FBI, HHS-OIG and MFCU and was brought as part of the Medicare Fraud Strike Force, supervised by the Criminal Division’s Fraud Section and the U.S. Attorney’s Office for the Northern District of Texas.
Since their inception in March 2007, Medicare Fraud Strike Force operations in nine locations have charged more than 1,190 defendants who collectively have falsely billed the Medicare program for more than $3.6 billion.
To learn more about the HEAT Strike Force, please visit: www.stopmedicarefraud.gov.
Also Arrested
WASHINGTON - A physician and the office manager of his medical practice, along with five owners of home health agencies, were arrested today on charges related to their alleged participation in a nearly $375 million health care fraud scheme involving fraudulent claims for home health services.
The arrests and charges were announced today by Deputy Attorney General James Cole and Health and Human Services (HHS) Deputy Secretary Bill Corr, along with Assistant Attorney General Lanny A. Breuer of the Justice Department’s Criminal Division; U.S. Attorney Sarah R. Saldaña of the Northern District of Texas; HHS Inspector General Daniel R. Levinson; Special Agent in Charge Robert E. Casey Jr. of the FBI’s Dallas Field Office; Dr. Peter Budetti, Deputy Administrator for Program Integrity for the Centers for Medicare and Medicaid Services (CMS); and the Texas Attorney General’s Medicaid Fraud Control Unit (MFCU).
The indictment, filed in the Northern District of Texas and unsealed today, charges Jacques Roy, M.D., 54, of Rockwall, Texas; Cynthia Stiger, 49, of Dallas; Wilbert James Veasey Jr., 60, of Dallas; Cyprian Akamnonu, 63, of Cedar Hill, Texas; Patricia Akamnonu, RN, 48, of Cedar Hill; Teri Sivils, 44, of Midlothian, Texas; and Charity Eleda, RN, 51, of Rowlett, Texas, each with one count of conspiracy to commit health care fraud. Roy also is charged with nine counts of substantive health care fraud, and Veasey, Patricia Akamnonu and Eleda are each charged with three counts of health care fraud. Eleda also is charged with three counts of making false statements related to a Medicare claim. All the defendants are expected to make their initial appearances at 2:00 p.m. CST today in federal court in Dallas.
In addition to the indictment, CMS announced the suspension of an additional 78 home health agencies (HHA) associated with Roy based on credible allegations of fraud against them.
Today’s enforcement actions are the result of the Medicare Fraud Strike Force operations, which are part of the Health Care Fraud Prevention & Enforcement Action Team (HEAT). HEAT is a joint initiative announced in May 2009 between the Department of Justice and HHS to focus their efforts to prevent and deter fraud and enforce anti-fraud laws around the country.
“The conduct charged in this indictment represents the single largest fraud amount orchestrated by one doctor in the history of HEAT and our Medicare Fraud Strike Force operations,” said Deputy Attorney General Cole. “Thanks to the historic partnerships we’ve built to combat health care fraud, we are sending a clear message: If you victimize American taxpayers, we will track you down and prosecute you.”
“Thanks to our new fraud detection tools, we have greater abilities to identify the kind of sophisticated fraud scheme that previously could have escaped scrutiny,” said HHS Deputy Secretary Corr. “Our aggressive Medicare Fraud Strike Force operations have enabled us to break up a significant alleged fraud operation and the fraud-fighting authorities in the Affordable Care Act have allowed us to stop further payments to providers connected to this scheme. This case and our new detection tools are examples of our growing ability to stop Medicare fraud.”
According to the indictment, Dr. Roy owned and operated Medistat Group Associates P.A. in the Dallas area. Medistat was an association of health care providers that primarily provided home health certifications and performed patient home visits. Dr. Roy allegedly certified or directed the certification of more than 11,000 individual patients from more than 500 HHAs for home health services during the past five years. Between January 2006 and November 2011, Medistat certified more Medicare beneficiaries for home health services and had more purported patients than any other medical practice in the United States. These certifications allegedly resulted in more than $350 million being fraudulently billed to Medicare and more than $24 million being fraudulently billed to Medicaid by Medistat and HHAs.
“Today, the Medicare Fraud Strike Force is taking aim at the largest alleged home health fraud scheme ever committed,” said Assistant Attorney General Breuer. “According to the indictment, Dr. Roy and his co-conspirators, for years, ran a well-oiled fraudulent enterprise in the Dallas area, making millions by recruiting thousands of patients for unnecessary services, and billing Medicare for those services. In Dallas, and the eight other Medicare Fraud Strike Force cities, the Criminal Division and our partners in the U.S. Attorneys’ Offices will continue to crack down on Medicare fraud, and hold accountable those stealing from the public fisc.”
“Fraud schemes, like the one we allege Dr. Roy executed, represent the next wave of Medicare and Medicaid crime that we face,” said U.S. Attorney Saldaña. “As enforcement actions have ramped up, not only in the Dallas Metroplex, but in several other areas throughout the country, fraudsters are devising new ways to beat the system. Rest assured, however, that with the tools and resources our district’s Medicare Care Fraud Strike Force provides, we will meet this challenge head-on and bring indictments against those who seek to defraud these critical programs, and you, the taxpayer.”
“Using sophisticated data analysis we can now target suspicious billing spikes,” said HHS Inspector General Levinson. “In this case, our analysts discovered that in 2010, while 99 percent of physicians who certified patients for home health signed off on 104 or fewer people – Dr. Roy certified more than 5,000.”
“The FBI views health care fraud as a severe crime problem,” said FBI Special Agent in Charge Casey. “It causes increased costs for consumers, tax payers and health insurance plans, and degrades the integrity of our health care system and legitimate patient care. Today’s arrests by the Dallas Medicare Fraud Strike Force send a clear message to those persons who are not only defrauding our federal Medicare and Medicaid and private health insurance programs, but victimizing the elderly, the disadvantaged, and those who are at a vulnerable time in their lives due to legitimate health issues. The FBI will continue to dedicate a substantial amount of expert resources to investigate these crimes.”
The indictment alleges that Dr. Roy used HHAs as recruiters so that Medistat could bill unnecessary home visits and medical services. Dr. Roy and other Medistat physicians certified and recertified plans of care so that HHAs also were able to bill Medicare for home health services that were not medically necessary and not provided. In addition, Dr. Roy allegedly performed unnecessary home visits and ordered unnecessary medical services.
According to the indictment, Medistat maintained a “485 Department,” named for the number of the Medicare form on which the plan of care was documented. Dr. Roy allegedly instructed Medistat employees to complete the 485s by either signing his name by hand or by using his electronic signature on the document.
Three of the HHAs Dr. Roy used as part of the scheme were Apple of Your Eye Healthcare Services Inc., owned and operated by Stiger and Veasey; Ultimate Care Home Health Services Inc., owned and operated by Cyprian and Patricia Akamnonu; and Charry Home Care Services Inc., owned and operated by Eleda. According to the indictment, Veasey, Akamnonu, Eleda and others recruited beneficiaries to be placed at their HHAs so that they could bill Medicare for the unnecessary and not provided services. As part of her role in the scheme, Eleda allegedly visited The Bridge Homeless Shelter in Dallas to recruit homeless beneficiaries staying at the facility, paying recruiters $50 per beneficiary they found at The Bridge and directed to Eleda’s vehicle parked outside the shelter’s gates.
Apple allegedly submitted claims to Medicare from Jan. 1, 2006, through July 31, 2011, totaling $9,157,646 for home health services to Medicare beneficiaries that were medically unnecessary and not provided. Dr. Roy or another Medistat physician certified the services. From Jan. 1, 2006, to Aug. 31, 2011, Ultimate submitted claims for medically unnecessary home health services totaling $43,184,628. Charry allegedly submitted fraudulent claims from Aug. 1, 2008, to June 30, 2011, totaling $468,858 in medically unnecessary and not provided home health services.
The indictment alleges that Sivils, as Medistat’s office manager, helped facilitate the fraud scheme by, among other actions, supervising the processing of thousands of plans of care that contained Dr. Roy’s electronic signature and other Medistat physicians’ signatures, permitting HHAs to bill Medicare for unnecessary home health services and accepting cash payments from Cyprian Akamnonu in exchange for ensuring plans of care contained Dr. Roy or another Medistat physician’s signature.
As outlined in the government’s request to the court to detain Dr. Roy, in June 2011, CMS suspended provider numbers for Dr. Roy and Medistat based on credible allegations of fraud, thus ensuring Dr. Roy did not receive payment from Medicare. Immediately after the suspension, nearly all of Medistat’s employees started billing Medicare under the provider number for Medcare HouseCalls. The court document alleges that Dr. Roy was in fact in charge of day-to-day operations at Medcare, and that Dr. Roy continued to certify patients for home health despite the suspension.
Each charged count of conspiracy to commit health care fraud and substantive health care fraud carries a maximum penalty of 10 years in prison and a $250,000 fine. Each false statement charge carries a maximum penalty of five years in prison and a $250,000 fine. The indictment also seeks forfeiture of numerous items including funds in bank accounts, a sailboat, vehicles and multiple pieces of property.
An indictment is merely an allegation and defendants are presumed innocent unless and until proven guilty beyond a reasonable doubt in a court of law.
The case is being prosecuted by Assistant U.S. Attorneys Michael C. Elliott, Mindy Sauter and John DeLaGarza of the Northern District of Texas and Trial Attorney Ben O’Neil and Deputy Chief Sam S. Sheldon of the Criminal Division’s Fraud Section. The case was investigated by the FBI, HHS-OIG and MFCU and was brought as part of the Medicare Fraud Strike Force, supervised by the Criminal Division’s Fraud Section and the U.S. Attorney’s Office for the Northern District of Texas.
Since their inception in March 2007, Medicare Fraud Strike Force operations in nine locations have charged more than 1,190 defendants who collectively have falsely billed the Medicare program for more than $3.6 billion.
To learn more about the HEAT Strike Force, please visit: www.stopmedicarefraud.gov.
Reducing Rehospitalizations… The Right Way
For several years, reducing rehospitalizations of Medicare beneficiaries has been a key public policy goal, the intent of which is to improve quality of care for beneficiaries and reduce costs for the Medicare program.[1] Studies have shown that rehospitalizations are common and expensive. In 2006, for example, nearly one-quarter of nursing home residents (23.5%) were rehospitalized within 30 days, at a cost to the Medicare program of $4.34 billion.[2] Yet, in many instances, nursing home residents' rehospitalizations are avoidable.[3]
However, reducing hospitalizations and rehospitalizations must be accomplished appropriately and with attention to the needs of residents. This is especially true in the current national environment where much of the emphasis in health care is on cost-containment, with increased penalties for unnecessary hospitalizations and rehospitalizations.
• Not all hospitalizations and rehospitalizations should be prevented. Some, given a patient's particular circumstances, may well be medically necessary and appropriate.[4] Moreover, denying Medicare beneficiaries the hospital care they actually need can be dangerous.
• It is important to avoid cost-shifting gimmicks. Labeling patients in the hospital as outpatients receiving observation care[5], for example, so that their initial time in the hospital is not counted as inpatient hospitalization and any return to the hospital is therefore not technically a rehospitalization (or, vice-versa, so that the initial time in the hospital is inpatient, the return, outpatient) is simply a semantic trick. It does not reduce patients' actual stays in acute care hospitals. Rather, for many Medicare beneficiaries, this gimmick only serves to increase their potential liability for the costs of outpatient Part B services and put Medicare-covered skilled nursing facility coverage out of reach.
Unnecessary rehospitalizations are correctly reduced by assuring, first, that patients are not prematurely discharged from acute care hospitals and second, that settings where patients receive post-acute care (such as skilled nursing facilities, SNFs) properly provide necessary post-hospital care services.
The Wrong Way to Reduce Rehospitalizations
Imposing artificial numbers of reductions in hospitalizations and rehospitalizations is, by itself, the wrong approach. There are already too many instances in which nursing home residents who need to be hospitalized are not. As Drs. Joseph G. Ouslander and Robert A. Berenson wrote in The New England Journal of Medicine in September 2011, "not all hospitalizations for conditions that can theoretically be managed outside an acute care hospital are preventable" and "not all nursing homes have the capacity to safely evaluate and manage changes in the condition of the clinically complex nursing home population."[6] They conclude, "Setting unrealistic expectations and providing incentives to poorly prepared nursing homes to manage such care rather than transferring residents to a hospital could have unintended negative effects on the quality of care and health outcomes."[7]
Unfortunately, legislation being promoted in Congress to save Medicare dollars would require the Secretary of the Department of Health and Human Services to establish a hospital readmission reduction target rate for skilled nursing facilities, using a baseline hospital readmission rate (as of October 1, 2011) and the goal of achieving aggregate Medicare savings of $2 billion for 2014 through 2021. Simply requiring nursing facilities to reduce their rates of hospitalization and rehospitalization, but not requiring them simultaneously to take steps to assure that residents who remain in the facility receive the care they need, could harm patients.
The Right Way to Reduce Rehospitalizations
Rehospitalizations can be reduced if nursing facilities are appropriately staffed to meet the complex health care needs of their residents. Many studies have demonstrated that improved staffing in nursing facilities (particularly, registered nurses, nurse practitioners, and physicians) can lead to the appropriate reduction of hospitalizations.[8]
The Centers for Medicare & Medicaid Services's (CMS's) Medicare-Medicaid Coordination Office, in collaboration with the Center for Medicare and Medicaid Innovation, is now establishing "a new initiative to help States improve the quality of care for people in nursing facilities by reducing preventable hospitalizations."[9]
CMS will competitively select independent organizations to partner with and implement evidence-based interventions at interested nursing facilities. These interventions could include using nurse practitioners in nursing facilities, supporting transitions between hospitals and nursing facilities, and implementing best practices to prevent falls, pressure ulcers, urinary tract infections, or other events that lead to poor health outcomes and expensive hospitalizations.[10]
This initiative builds on studies demonstrating the importance of staffing at nursing facilities as a key way to reduce hospitalization.
CMS funded a pilot quality improvement project in three nursing facilities in Georgia from May 1 to October 31, 2007. The pilot facilities reported an average reduction of hospitalizations of 50% over the six-month period. The project's Expert Panel identified as key factors for "preventing avoidable hospitalizations…greater on-site availability of physician or nurse practitioner or physician assistants, more registered nurses providing care, availability of lab results within 3 hours, and the capability of the NH to administer intravenous fluids."[11]
The nursing home chain, Life Care Centers of America, reports that it reduced rehospitalizations from 40% to 15% in one year in its facilities that employed a full-time physician.[12] Additional benefits of the employment of physicians in nursing facilities reported by the corporation were reduced use of antipsychotic drugs, "reduced staff turnover, greater resident and family satisfaction, and improved clinical outcomes."
As the Center for Medicare Advocacy wrote in an Alert from March 2011, earlier studies of hospitalization of nursing home residents found that hospitalization could be reduced if facilities employed geriatric nurse practitioners,[13] physicians, nurse practitioners, and physician assistants.[14] The nursing home corporation Genesis HealthCare reported that it employed more registered nurses, nurse practitioners, and physicians in its nursing facilities, resulting in an 11% decline in unplanned hospitalizations since 2004. Sixty percent of Genesis facilities have a "'transitional care unit,' in which an RN-intensive staff team cares for residents who have been in the hospital within the past 25 days."[15] The RNs "are intravenous (IV)-certified." The transitional care units also have a nurse practitioner or physician on staff every day.
Reducing rehospitalization by increasing staffing in nursing homes is not a new idea. In an article published 23 years ago, reporting research conducted between 1985 and 1988, Professor Jeanne Kayser-Jones of the University of California, San Francisco, identified various factors that contributed to the hospitalization of nursing home residents. Professor Kayser-Jones found that almost half the hospitalizations were unnecessary and that the residents could have been cared for in their nursing homes. The predominant factor causing hospitalization was "the insufficient number of adequately trained nursing staff."[16]
Conclusion
Reducing hospitalizations and rehospitalizations is a worthy goal so long as policymakers first recognize that:
• Many hospitalizations and rehospitalizations are medically necessary and appropriate,
• Hospitalized patients should not be misclassified as observation status outpatients, and
• Nursing homes must be appropriately staffed so that Medicare beneficiaries receive the care they need.
For more information, contact attorney Toby S. Edelman (tedelman@medicareadvocacy.org) in the Center for Medicare Advocacy's Washington, DC office at (202) 293-5760.
________________________________________
[1] Misha Segal, "Dual Eligible Beneficiaries and Potentially Avoidable Hospitalizations," (CMS, Center for Strategic Planning, Policy Insight Brief) (Sep. 2011), https://www.cms.gov/Insight-Briefs/downloads/PAHInsightBrief.pdf [hereafter "Dual Eligible Beneficiaries and Potentially Avoidable Hospitalizations"]. A recent White Paper for the Long-Term Quality Alliance discusses three separate themes of research literature on this broad topic: hospitalization from the community, hospitalization from nursing homes, and hospital readmissions. Katie Maslow, Joseph G. Ouslander, "Measurement of Potentially Preventable Hospitalizations" (White Paper prepared for the Long-Term Quality Alliance) (Feb. 2012), http://www.ltqa.org/wp-content/themes/ltqaMain/custom/
images//PreventableHospitalizations_021512_2.pdf [hereafter "Measurement of Potentially Preventable Hospitalizations"].
[2] Vincent Mor, Orna Intrator, Zhanlian Feng, David C. Grabowski, "The Revolving Door Of Rehospitalization From Skilled Nursing Facilities," Health Affairs 29, No. 1 (2010): 57-64.
[3] Stephen F. Jencks, Mark V Williams, Eric A. Coleman, "Rehospitalizations among Patients in the Medicare Fee-for-Service Program," New England Journal of Medicine 360;14 (April 2, 2009),
[4] Joseph G. Ouslander, Robert Berenson, "Reducing Unnecessary Hospitalizations of Nursing Home Residents," New England Journal of Medicine 2011; 365: 1165-1167 (Sep. 29, 2011), http://www.nejm.org/doi/full/10.1056/NEJMp1105449 [hereafter "Reducing Unnecessary Hospitalizations of Nursing Home Residents"]; "Measurement of Potentially Preventable Hospitalizations," supra note 1.
[5] Patients in observation status are placed in hospital beds and receive medical and nursing care, diagnostic tests, treatments, prescription drugs, and food. But because they are in observation status, they are labeled outpatients. For more information about observation status, see Center for Medicare Advocacy, "Observation Status," http://www.medicareadvocacy.org/medicare-info/observation-status/. See also Kenneth R. Dardick, MD, Judith Stein, JD, "Hospital Readmission and Measures of Quality" Journal of American Medical Association, Vol. 301, No. 4 (January 25, 2012)
[6] "Reducing Unnecessary Hospitalizations of Nursing Home Residents," supra note 4. See also "Measurement of Potentially Preventable Hospitalizations," supra note 1.
[7] Id.
[8] See Center for Medicare Advocacy, "More Nurses in Nursing Homes Would Mean Fewer Patients Headed to Hospitals" (Weekly Alert, March 10, 2011), http://www.medicareadvocacy.org/2011/03/10/more-nurses-in-nursing-
homes-will-mean-fewer-patients-headed-to-hospitals/.
[9] "Dual Eligible Beneficiaries and Potentially Avoidable Hospitalizations," supra note 1.
[10] CMS, "Obama Administration Offers States New Ways to Improve Care, Lower Costs for Medicaid; Initiatives Focus on People Receiving Medicare and Medicaid Benefits" (Press Release, July 8, 2011), http://www.cms.gov/apps/media/press/release.asp?Counter=4024&intNumPerPage
=1000&checkDate=&checkKey=&srchType=1&numDays=0&srchOpt=
0&srchData=&keywordType=All&chkNewsType=1%2C+2%2C+3%2C+
4%2C+5&intPage=&showAll=1&pYear=1&year=2011&desc=false&cboOrder=date.
[11] Joseph G. Ouslander, Mary Perloe, JoVonn H. Givens, Linda Kluge, Tracy Rutland, and Gerri Lamb, "Reducing Potentially Avoidable Hospitalizations of Nursing Home Residents: Results of a Pilot Quality Improvement Project," Journal of the American Medical Directors Association, DOI:10.1016/j.jamda.2009.07.001 (2009). Abstract available at http://www.jamda.com/article/S1525-8610(09)00248-5/abstract.
[12] Kathleen Lourde, "Physicians Moving In; Life Care Centers of America hires full-time, facility-based physicians to reduce rehospitalizations," Provider (Feb. 2012), http://www.providermagazine.com/archives/archives-2012/
Pages/0212/Physicians-Moving-In.aspx.
[13] William H. Barker, James G. Zimmer, W. Jackson Hall, Brian C. Ruff, Charlene B. Freundlich, and Gerald M. Eggert, "Rates, Patterns, Causes, and Costs of Hospitalization of Nursing Home Residents: A Population-Based Study," American Journal of Public Health, 1994; 84:1615-1620.
[14] Joseph G. Ouslander, Gerri Lamb, Mary Perloe, JoVonn H. Givens, Linda Kluge, Tracy Rutland, Adam Atherly, and Debra Saliba, "Potentially Avoidable Hospitalizations of Nursing Home Residents: Frequency, Causes, and Costs," Journal of the American Geriatrics Society 58:627-635, 2010.
[15] Kathleen Lourde, "Providers Tackle Preventable Hospitalizations: Nursing facilities ramp up efforts to care for higher acuity residents," Provider (Jan. 2011), http://www.providermagazine.com/archives/archives-2011/
Pages/0111/Ramping-Up-For-Higher-Acuity.aspx.
[16] J.S. Kayser-Jones, Carolyn L. Wiener, Joseph C. Barbaccia, "Factors Contributing to the Hospitalization of Nursing Home Residents," The Gerontologist 502 (1989).
However, reducing hospitalizations and rehospitalizations must be accomplished appropriately and with attention to the needs of residents. This is especially true in the current national environment where much of the emphasis in health care is on cost-containment, with increased penalties for unnecessary hospitalizations and rehospitalizations.
• Not all hospitalizations and rehospitalizations should be prevented. Some, given a patient's particular circumstances, may well be medically necessary and appropriate.[4] Moreover, denying Medicare beneficiaries the hospital care they actually need can be dangerous.
• It is important to avoid cost-shifting gimmicks. Labeling patients in the hospital as outpatients receiving observation care[5], for example, so that their initial time in the hospital is not counted as inpatient hospitalization and any return to the hospital is therefore not technically a rehospitalization (or, vice-versa, so that the initial time in the hospital is inpatient, the return, outpatient) is simply a semantic trick. It does not reduce patients' actual stays in acute care hospitals. Rather, for many Medicare beneficiaries, this gimmick only serves to increase their potential liability for the costs of outpatient Part B services and put Medicare-covered skilled nursing facility coverage out of reach.
Unnecessary rehospitalizations are correctly reduced by assuring, first, that patients are not prematurely discharged from acute care hospitals and second, that settings where patients receive post-acute care (such as skilled nursing facilities, SNFs) properly provide necessary post-hospital care services.
The Wrong Way to Reduce Rehospitalizations
Imposing artificial numbers of reductions in hospitalizations and rehospitalizations is, by itself, the wrong approach. There are already too many instances in which nursing home residents who need to be hospitalized are not. As Drs. Joseph G. Ouslander and Robert A. Berenson wrote in The New England Journal of Medicine in September 2011, "not all hospitalizations for conditions that can theoretically be managed outside an acute care hospital are preventable" and "not all nursing homes have the capacity to safely evaluate and manage changes in the condition of the clinically complex nursing home population."[6] They conclude, "Setting unrealistic expectations and providing incentives to poorly prepared nursing homes to manage such care rather than transferring residents to a hospital could have unintended negative effects on the quality of care and health outcomes."[7]
Unfortunately, legislation being promoted in Congress to save Medicare dollars would require the Secretary of the Department of Health and Human Services to establish a hospital readmission reduction target rate for skilled nursing facilities, using a baseline hospital readmission rate (as of October 1, 2011) and the goal of achieving aggregate Medicare savings of $2 billion for 2014 through 2021. Simply requiring nursing facilities to reduce their rates of hospitalization and rehospitalization, but not requiring them simultaneously to take steps to assure that residents who remain in the facility receive the care they need, could harm patients.
The Right Way to Reduce Rehospitalizations
Rehospitalizations can be reduced if nursing facilities are appropriately staffed to meet the complex health care needs of their residents. Many studies have demonstrated that improved staffing in nursing facilities (particularly, registered nurses, nurse practitioners, and physicians) can lead to the appropriate reduction of hospitalizations.[8]
The Centers for Medicare & Medicaid Services's (CMS's) Medicare-Medicaid Coordination Office, in collaboration with the Center for Medicare and Medicaid Innovation, is now establishing "a new initiative to help States improve the quality of care for people in nursing facilities by reducing preventable hospitalizations."[9]
CMS will competitively select independent organizations to partner with and implement evidence-based interventions at interested nursing facilities. These interventions could include using nurse practitioners in nursing facilities, supporting transitions between hospitals and nursing facilities, and implementing best practices to prevent falls, pressure ulcers, urinary tract infections, or other events that lead to poor health outcomes and expensive hospitalizations.[10]
This initiative builds on studies demonstrating the importance of staffing at nursing facilities as a key way to reduce hospitalization.
CMS funded a pilot quality improvement project in three nursing facilities in Georgia from May 1 to October 31, 2007. The pilot facilities reported an average reduction of hospitalizations of 50% over the six-month period. The project's Expert Panel identified as key factors for "preventing avoidable hospitalizations…greater on-site availability of physician or nurse practitioner or physician assistants, more registered nurses providing care, availability of lab results within 3 hours, and the capability of the NH to administer intravenous fluids."[11]
The nursing home chain, Life Care Centers of America, reports that it reduced rehospitalizations from 40% to 15% in one year in its facilities that employed a full-time physician.[12] Additional benefits of the employment of physicians in nursing facilities reported by the corporation were reduced use of antipsychotic drugs, "reduced staff turnover, greater resident and family satisfaction, and improved clinical outcomes."
As the Center for Medicare Advocacy wrote in an Alert from March 2011, earlier studies of hospitalization of nursing home residents found that hospitalization could be reduced if facilities employed geriatric nurse practitioners,[13] physicians, nurse practitioners, and physician assistants.[14] The nursing home corporation Genesis HealthCare reported that it employed more registered nurses, nurse practitioners, and physicians in its nursing facilities, resulting in an 11% decline in unplanned hospitalizations since 2004. Sixty percent of Genesis facilities have a "'transitional care unit,' in which an RN-intensive staff team cares for residents who have been in the hospital within the past 25 days."[15] The RNs "are intravenous (IV)-certified." The transitional care units also have a nurse practitioner or physician on staff every day.
Reducing rehospitalization by increasing staffing in nursing homes is not a new idea. In an article published 23 years ago, reporting research conducted between 1985 and 1988, Professor Jeanne Kayser-Jones of the University of California, San Francisco, identified various factors that contributed to the hospitalization of nursing home residents. Professor Kayser-Jones found that almost half the hospitalizations were unnecessary and that the residents could have been cared for in their nursing homes. The predominant factor causing hospitalization was "the insufficient number of adequately trained nursing staff."[16]
Conclusion
Reducing hospitalizations and rehospitalizations is a worthy goal so long as policymakers first recognize that:
• Many hospitalizations and rehospitalizations are medically necessary and appropriate,
• Hospitalized patients should not be misclassified as observation status outpatients, and
• Nursing homes must be appropriately staffed so that Medicare beneficiaries receive the care they need.
For more information, contact attorney Toby S. Edelman (tedelman@medicareadvocacy.org) in the Center for Medicare Advocacy's Washington, DC office at (202) 293-5760.
________________________________________
[1] Misha Segal, "Dual Eligible Beneficiaries and Potentially Avoidable Hospitalizations," (CMS, Center for Strategic Planning, Policy Insight Brief) (Sep. 2011), https://www.cms.gov/Insight-Briefs/downloads/PAHInsightBrief.pdf [hereafter "Dual Eligible Beneficiaries and Potentially Avoidable Hospitalizations"]. A recent White Paper for the Long-Term Quality Alliance discusses three separate themes of research literature on this broad topic: hospitalization from the community, hospitalization from nursing homes, and hospital readmissions. Katie Maslow, Joseph G. Ouslander, "Measurement of Potentially Preventable Hospitalizations" (White Paper prepared for the Long-Term Quality Alliance) (Feb. 2012), http://www.ltqa.org/wp-content/themes/ltqaMain/custom/
images//PreventableHospitalizations_021512_2.pdf [hereafter "Measurement of Potentially Preventable Hospitalizations"].
[2] Vincent Mor, Orna Intrator, Zhanlian Feng, David C. Grabowski, "The Revolving Door Of Rehospitalization From Skilled Nursing Facilities," Health Affairs 29, No. 1 (2010): 57-64.
[3] Stephen F. Jencks, Mark V Williams, Eric A. Coleman, "Rehospitalizations among Patients in the Medicare Fee-for-Service Program," New England Journal of Medicine 360;14 (April 2, 2009),
[4] Joseph G. Ouslander, Robert Berenson, "Reducing Unnecessary Hospitalizations of Nursing Home Residents," New England Journal of Medicine 2011; 365: 1165-1167 (Sep. 29, 2011), http://www.nejm.org/doi/full/10.1056/NEJMp1105449 [hereafter "Reducing Unnecessary Hospitalizations of Nursing Home Residents"]; "Measurement of Potentially Preventable Hospitalizations," supra note 1.
[5] Patients in observation status are placed in hospital beds and receive medical and nursing care, diagnostic tests, treatments, prescription drugs, and food. But because they are in observation status, they are labeled outpatients. For more information about observation status, see Center for Medicare Advocacy, "Observation Status," http://www.medicareadvocacy.org/medicare-info/observation-status/. See also Kenneth R. Dardick, MD, Judith Stein, JD, "Hospital Readmission and Measures of Quality" Journal of American Medical Association, Vol. 301, No. 4 (January 25, 2012)
[6] "Reducing Unnecessary Hospitalizations of Nursing Home Residents," supra note 4. See also "Measurement of Potentially Preventable Hospitalizations," supra note 1.
[7] Id.
[8] See Center for Medicare Advocacy, "More Nurses in Nursing Homes Would Mean Fewer Patients Headed to Hospitals" (Weekly Alert, March 10, 2011), http://www.medicareadvocacy.org/2011/03/10/more-nurses-in-nursing-
homes-will-mean-fewer-patients-headed-to-hospitals/.
[9] "Dual Eligible Beneficiaries and Potentially Avoidable Hospitalizations," supra note 1.
[10] CMS, "Obama Administration Offers States New Ways to Improve Care, Lower Costs for Medicaid; Initiatives Focus on People Receiving Medicare and Medicaid Benefits" (Press Release, July 8, 2011), http://www.cms.gov/apps/media/press/release.asp?Counter=4024&intNumPerPage
=1000&checkDate=&checkKey=&srchType=1&numDays=0&srchOpt=
0&srchData=&keywordType=All&chkNewsType=1%2C+2%2C+3%2C+
4%2C+5&intPage=&showAll=1&pYear=1&year=2011&desc=false&cboOrder=date.
[11] Joseph G. Ouslander, Mary Perloe, JoVonn H. Givens, Linda Kluge, Tracy Rutland, and Gerri Lamb, "Reducing Potentially Avoidable Hospitalizations of Nursing Home Residents: Results of a Pilot Quality Improvement Project," Journal of the American Medical Directors Association, DOI:10.1016/j.jamda.2009.07.001 (2009). Abstract available at http://www.jamda.com/article/S1525-8610(09)00248-5/abstract.
[12] Kathleen Lourde, "Physicians Moving In; Life Care Centers of America hires full-time, facility-based physicians to reduce rehospitalizations," Provider (Feb. 2012), http://www.providermagazine.com/archives/archives-2012/
Pages/0212/Physicians-Moving-In.aspx.
[13] William H. Barker, James G. Zimmer, W. Jackson Hall, Brian C. Ruff, Charlene B. Freundlich, and Gerald M. Eggert, "Rates, Patterns, Causes, and Costs of Hospitalization of Nursing Home Residents: A Population-Based Study," American Journal of Public Health, 1994; 84:1615-1620.
[14] Joseph G. Ouslander, Gerri Lamb, Mary Perloe, JoVonn H. Givens, Linda Kluge, Tracy Rutland, Adam Atherly, and Debra Saliba, "Potentially Avoidable Hospitalizations of Nursing Home Residents: Frequency, Causes, and Costs," Journal of the American Geriatrics Society 58:627-635, 2010.
[15] Kathleen Lourde, "Providers Tackle Preventable Hospitalizations: Nursing facilities ramp up efforts to care for higher acuity residents," Provider (Jan. 2011), http://www.providermagazine.com/archives/archives-2011/
Pages/0111/Ramping-Up-For-Higher-Acuity.aspx.
[16] J.S. Kayser-Jones, Carolyn L. Wiener, Joseph C. Barbaccia, "Factors Contributing to the Hospitalization of Nursing Home Residents," The Gerontologist 502 (1989).
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