Welcome to AmeriChoice of Pennsylvania

On behalf of AmeriChoice of Pennsylvania, I would like to welcome you as a participating provider in our Medicaid and Children’s Health Insurance Program (CHIP) products. We are committed to working with you and your staff to achieve the best possible outcomes for our members. This welcome kit contains valuable information about important contacts, policies, procedures and services to help you to conduct business with us as efficiently as possible. For easy navigation through the kit components, you can click on each link in the Table of Contents, which will bring you directly to that section. You can also download the Physician, Health Care Professional, Facility and Ancillary Administrative Guide by logging on to www.americhoice.com . This is a comprehensive reference source for the information you and your staff need regarding claims, benefits, prior authorization, medical management and other plan components. Again, we are pleased that you are one of our participating providers delivering quality care to our members. If you have any questions about your participation with AmeriChoice, or need a printed copy of this welcome kit, please call the Provider Service Helpline at 1-800-345-3627.

Sincerely,

Ernest Monfiletto Pennsylvania-East, Chief Executive Officer AmeriChoice of Pennsylvania AmeriChoice Provider Welcome Kit

This chart identifies bonus payments available to you, in addition to your regular payments, for compliance with HEDIS measures as defined by the National Committee for Quality Assurance (NCQA). For more information, call Jessica Anglin at 215-832-4590.

AmeriChoice Provider Welcome Kit This chart identifies bonus payments available to you, in addition to your regular payments, for compliance with HEDIS measures as defined by the National Committee for Quality Assurance (NCQA). For more information, call Jessica Anglin at 215-832-4590. Provider Incentives Measure Requirements AmeriChoice Will Available Referrals Adolescent Well-Care • Provider Incentive:$100/4th qtr 2008 only;$50/visit all other months • Member Incentive: 2 movie tickets Ages 12–21 years • Well-care visit • Physical exam • History of health & development • Education & guidance • Call members • Offer auto messaging for providers • Mail reminders • Provide member list with addresses and phone numbers • Provide EPSDT grid Healthy First Steps® (HFS) 877-651-6667 Lead Screening • Provider Incentive: $15/submitted test • Member Incentive:$15 VISA gift card • Documented levels • 9-19 months and <3rd birthday • Call members • Provide Case Management for elevated levels • Offer auto messaging for providers • Provide member list with addresses and phone numbers • Provide MEDTOX in-office testing MEDTOX 877-725-7241 Healthy First Steps (HFS) 877-651-6667 Childhood Immunizations All immunizations • Call members • Mail reminders • Review registry for Philadelphia County • Offer uto messaging for providers • Provide EPSDT grid Healthy First Steps (HFS) 877-651-6667 BMI Ages 2-20 years Documentation in chart • Offer auto messaging for providers • Offer BMI wheel Healthy First Steps (HFS) 877-651-6667 Dental Screenings Ages 2-20 years • Mail reminders • Call members • Offer auto messaging for providers Healthy First Steps (HFS) 877-651-6667 Case Management 877-651-6667 Asthma Ages 5-56 years • Identify as having persistent asthma • At least one Rx • Preferred asthma therapy education• Create member medication profiles • Call members • Provide Case Management referrals • Offer LifeLink Case Management 877-651-6667

AmeriChoice Provider Welcome Kit Pa

Measure Requirements AmeriChoice Will Available Referrals Breast Cancer • Member Incentive: $50 VISA gift card Mammogram Females, Ages 40-69 years • Call members • Mail reminders • Offer auto messaging for providers • Assist in locating providers and scheduling appointments • Assist with ransportation QM Coordinator 215-832-4524 Case Management 877-651-6667 Cervical Cancer Screening (PAP) • Member Incentive: $25 VISA gift card Females, Ages 21-64 years • Call members • Mail reminders • Offer auto messaging for providers • Assist in locating providers and scheduling appointments • Assist with transportation QM Coordinator 215-832-4524 (to help schedule) Case Management 877-651-6667 Diabetes Care Provider Incentive: • Phase 1: Completed E and M visit ($100.00) and completed Cholesterol and HbA1C Screening • Phase 2: Diabetes managed – ($150.00); Cholesterol below 100 mg; HbA1c below 9 Ages 18-75 • HbA1C testing and documentation <9 • LDL screening and documentation <100 mg/dL) • Retinal eye exam performed • Blood pressure control • (<140/90 mm Hg) • Nephropathy screening test Urine macroalbumin ? Visit to nephrologist ? Treatment for nephropathy ? Therapy with ACE inhibitor/ARBs • Call members • Mail reminders • Provide Case Management • Offer auto messaging for providers Case Management 877-651-6667 Frequency of Ongoing Prenatal Care • Provider ncentive: $250 for completed prenatal intake form • Submission of completed prenatal intake form by provider • FAX to AmeriChoice HFS at 215-832-4986 • Provide Case Management Healthy First Steps (HFS) 877-651-6667 ER Diversion • Decrease overutilization of ER services for non-urgent diagnosis • Call members • Provide Case Management Case Management 877-651-6667

DOJ Charges PA Swim Club With Racism From the Philadelphia Inquirer U.S. charges Montco swim club with racism

By Derrick Nunnally January 14, 2010 The U.S. Justice Department accused a Huntingdon Valley swim club of racism in a federal lawsuit filed yesterday as the club deals with ongoing bankruptcy proceedings. The Valley Club, which revoked its contract with the Creative Steps day camp after 56 black and Latino children visited June 29, is charged in the suit with making a no-summer-campers rule the next day "in response to racially motivated opposition from Valley Club members . . . with the intention of preventing the children of Creative Steps from returning.

Does anyone enforce the Law? Why is this company never questioned? How about taxpayers money used for pool Medicaid beneficiaries?How about Americhoice Health spenfing it's money to further it's position against all the rules,laws and regulations? Collaborate, is that a new use for this worg for buying their business? Is this considered Honest Fraud, under the new Federal Judicial thinking that taxpayers would never vote for or approve? Why are the DOJ and its employees immune from any civil actions? What is their priority system in effect for any violations, just politics?

AmeriChoice is proud to collaborate with Mayor Nutter’s administration for the second consecutive year to help overcome the obstacles that could have resulted in the City closing its pools this summer,said Executive Director of Pennsylvania East AmeriChoice Ernie Monfiletto. Following the check presentation, AmeriChoice was presented with a health care Innovation Award by the National Association of Health Services Executives in recognition of its services to its Medicaid and Children’s Health Insurance (CHIP) members. Hey, and all this is all on film with current and potential beneficiaries applauding. How about that award received for breaking every rule, law, and regulation they receive Government money not to do.

2009 and 2010 $120,000 blatant inducements from your tax dollars for the protected Medicaid vendor. Philadelphia PA Mayor Nutter received two years in a row $60,000 checks to help keep open and operate the city swimming pools. These checks came from AmeriChoice Health and on the surface seems like fine gifts.Yet, they are Bribes non the less, these checks come from a company who receives all its money from the Federal Government as a vendor for Medicare Medicaid services is not allowed to offer bribes kickbacks and money gifts of any kind inducements in order to promote its share of the market place. This is not allowed as a use of your taxpayers dollars yet it happens.What will it really cost the City of Philadelphia to receive this money? Americhoice Health has a long history of corruption over the years yet seems to be protected by those who are responsible to over see their actions why is that? Inducement. Section 1128A(a)(5) of the Act bars the offering of remuneration to Medicare or Medicaid beneficiaries where the person offering the remuneration knows or should know that the remuneration is likely to influence the beneficiary to order or receive items or services from a particular provider. The "should know" standard is met if a provider acts with deliberate ignorance or reckless disregard. No proof of specific intent is required.

Among its provisions, the anti-kickback statute penalizes anyone who knowingly and willfully solicits, receives, offers or pays remuneration in cash or in kind to induce, or in return for: A. Referring an individual to a person for the furnishing, or arranging for the furnishing, of any item or service payable under the Medicare or Medicaid program; or B. Purchasing, leasing or ordering , or arranging for or recommending purchasing, leasing or ordering, any goods, facility, service or item payable under the Medicare or Medicaid program. Violators are subject to criminal penalties, or exclusion from participation in the Medicare and Medicaid rograms, or both. A violation of the anti-kickback law is a felony offense that carries criminal fines of up to $25,000 per violation, imprisonment for up to five years and exclusion from government health care programs.The federal anti-kickback statute, 42 U.S.C.§ 1320a-7b(b), prohibits individuals or entities from knowingly and willfully offering, paying, soliciting or receiving remuneration to induce referrals of items or services covered by Medicare, Medicaid or any other federally funded program. For purposes of the anti-kickback statute, "remuneration" includes the transfer of anything of value, directly or indirectly, overtly or covertly, in cash or in-kind

If this were any one person they would be in jail now, if the FBI were called in on this matter they would be in jail now, if the IRS were notified they would be in jail now. Since all Ameri-Choice checks come from the United Health's home office they should be held equally responsible for any bribes, kickbacks, Stark, Fraud and inducements violations that have occured. Federal and State Governments have developed such a depended position with this company that laws and rules no longer apply for them.This role is nothing new for the AmeriChoice people and its been going on for years, look at some of the prior news articles that date back for years only now they can afford to hire the best of Law firms and give the most for Political contributations all on the back of the taxpayer.

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]

Limo Divers Protest Medicare Mediciad Reform Cuts, It's rumored this issue could become part of the Tea Party movement. AmeriChoice Health also rumored to take a position on this issue. Recirculate those tax dollars? Help keep limo drivers working, benefits flowing and overpaid tax dollars remain in abuse.

Medicare.gov as well as other Federal agency's encourage you to report any fraudulent activities, yet, the same government agency's were notified the way this company does business yet did nothing. Three years ago they were reported to these Federal agency's and as of todays date not only were they allowed to continue doing business but were never charged once. Protected vendor status sure, politics sure, limited government budgets sure, Federal and State officals looking the other way sure, and rather then stop these activities a strong desire not to rock the boat previals. Even with the vast changes in the laws, budgets,a hands off policy remains, you tell me what's wrong with this picture?

The Government created this monster and now they don't know what to do about it, like shooting yourself in your own foot etc. Tons of money to advance their national growth, it's market positions, tons of money for political donations, tons of money to send 75 millIon back to its home office from New York state alone, tons of money to suppot National TV shows, tons of money to pay hugh State fines, tons of money to hire the very best law firms, tons of money to pay for bribes and kickbacks, tons of money for hugh salary's and bonuses, all done on the back of the American tax payor, you see this company receives all it's money from the Federal government. Should your tax dollars be held to a higher standard? Should our government agency's responsible for there review and be held to that same standard? Should the IRS audit their corruption? Why has this company not been charged? How long can the buck be passed here in more ways then one?

Hey, it's your tax dollars don't complain now.. then don't complain later on…

ps… I know times are tough for a lot us, but it would be great to have a free limo to go to the Doctors, Pharmacy, Movies, Grocery shopping, and given free tickets for the movies. Offered soda, pop corn and hotdogs, as well as have them receive free coupons for Grocery items…Kind of makes you wish qualified for Medicare and Mediciad right?

For three years now, a woman has left her home in Poughkeepsie, New York, five days a week and taken a taxi to visit her child at St. Margaret’s Center, a nursing home for disabled children in Albany, New York. Each night, she rides home by taxi. That costs $300 a day. What dedication by taxpayers. That is right. Taxpayers have shelled out $196,000 over the past three years so that she can make this Poughkeepsie-Albany commute each day. Incredibly, state health officials defended this daily abuse of taxpayers. Could not the woman move to Albany? It would have been cheaper to buy her a Cadillac Escalade and have her drive herself. But under Medicaid’s incomprehensibly illogical rules, taxpayers had to give this woman a whopping $65,000 subsidy. We underpay doctors by 20% or more. But one — likely two — cab drivers have a gravy train going there. For New York state, the bill comes to $98,000 — with federal taxpayers shelling out another $98,000.

Oh and this happens all over the place. Ambulances in Southern West Virginia became taxis as they shuttled people off to the drug store and the like — and then billed Medicaid. New York state Comptroller Thomas P. DiNapoli said the $196,000 taxi drive was part of at least $169 million in misspent funds. “We found the state Medicaid system is leaking millions of dollars,” DiNapoli told the Albany Times-Union. “Safeguards designed to protect the taxpayers by detecting waste, fraud and abuse keep failing.” Taxpayers finance $196,000 ride By CATHLEEN F. CROWLEY Staff Writer Published: 01:00 a.m., Wednesday, December 23, 2009

Fraud and Abuse Implications of Free Transportation Services Issued: November 17, 2000

Posted: November 24, 2000

Re: OIG Advisory Opinion No. 00-7

Health care providers that offer free goods or services, such as free transportation services, to Federal health care beneficiaries may be subject to civil monetary penalties. In section 1128A(a)(5) of the Act, Congress specifically addressed the issue of providers offering remuneration to Medicare and Medicaid beneficiaries in order to influence their selection of a particular provider by authorizing the imposition of civil monetary penalties against such providers. Moreover, free transportation services may implicate the criminal anti-kickback statute which prohibits offering anything of value to any "person" (including a Federal health care beneficiary) to reward or induce referrals (including self-referrals) for items or services reimbursable under any Federal health care program.(1) Given the overlap between the two statutes, we will begin with some general observations about free transportation services.(2)

First, we recognize that many arrangements involving free transportation have important and beneficial effects on patient care, especially where such arrangements are narrowly tailored to address issues of financial need, limited transportation resources, treatment compliance, or safety.

Second, we also recognize that free transportation services are sometimes an integral part of fraudulent or abusive schemes which lead to inappropriate steering of patients, overutilization, and the provision of medically unnecessary services. Examples of abusive arrangements involving free transportation services include:

Psychiatric facilities offering out-of-state patients free round-trip airline tickets to Florida in order to receive services at their facilities;
Van drivers soliciting, and offering free transportation services to, Medicaid patients for health care providers who compensate the drivers on a per patient or per service basis;
Unscrupulous health care providers offering residents of nursing facilities and other congregate care facilities free transportation services to and from their offices for services that are frequently of questionable necessity;
Hospitals offering patients free limousine services; and
Hospitals offering patients free ambulance services without making individual determinations of financial need.
Third, given their potential for abuse, we evaluate arrangements involving free transportation services on a case-by-case basis. We have identified several risk factors including, but not limited to, the following:

The population to whom free transportation services are offered. While free transportation services offered to "all comers" can implicate section 1128A(a)(5) of the Act and the anti-kickback statute, so can free transportation services offered to select patients or populations. To the extent the services are offered selectively, we evaluate the basis on which the selection is made. For example, an offeror of free transportation services might select individuals based upon one or more of the following criteria: relationship with the offeror (including physician-patient relationships); relationship with other providers (including nursing facility-resident relationships); diagnosis; insurance coverage; geographic location; financial need; or concerns regarding safety or treatment compliance.
The nature or type of free transportation services offered. Expensive transportation services such as limousines, airline tickets, or ambulance transports raise greater concerns.
The geographic area in which free transportation services are offered. Services offered within a provider's historic service area are less suspect than services offered outside its historic service area.
The availability and affordability of alternate means of transportation.
Whether free transportation services are marketed or advertised and, if so, how.
The type of provider offering the free transportation services. Free transportation services offered by individual or small groups of providers, including physicians, or by freestanding clinics are subject to greater scrutiny. Historically, unscrupulous providers and clinics have offered free transportation services in conjunction with Medicare and Medicaid mills.
Whether the costs of the free transportation services will be claimed directly or indirectly on any Federal health care program cost report or claim or otherwise shifted to any Federal health care program.
These factors are not exclusive, and the presence or absence of any one factor is not determinative of whether the OIG would subject parties to sanctions for providing free transportation services to patients.

Fourth, we weigh these factors, as well as other relevant concerns, in assessing the level of risk presented by an arrangement. They are not necessarily determinative or probative of whether an arrangement violates the applicable statutes. The elements required for a violation of the statutes are discussed below.

B. Application of Section 1128A(a)(5) of the Act

Section 1128A(a)(5) of the Act provides for the imposition of civil monetary penalties against any person who:

offers or transfers remuneration to any individual eligible for benefits under [Medicare or a State health care program] that such person knows or should know is likely to influence such individual to order or receive from a particular provider, practitioner, or supplier any item or service for which payment may be made, in whole or in part, under [Medicare or a State health care program].

See also 65 Fed. Reg. 24400, 24416 (April 26, 2000) (to be codified at 42 C.F.R. § 1003.102(b)(13)). Section 1128A(i)(6) of the Act defines "remuneration" for purposes of section 1128A(a)(5) of the Act as including, among other things, "transfers of items or services for free or for other than fair market value." Unlike the anti-kickback statute, section 1128A(a)(5) of the Act is solely concerned with remuneration offered or transferred to Medicare or State health care program beneficiaries.

Although free transportation services clearly fall within the ambit of the prohibition, legislative history indicates that, in enacting section 1128A(a)(5), Congress did not intend to impose civil monetary penalties against persons offering complimentary local transportation of nominal value. H.R. Conf. Rep. No. 104-736, at 255 (1996). In the preamble to 42 C.F.R. § 1003.102(b)(13), the final rule addressing section 1128A(a)(5) of the Act, we interpreted nominal value for purposes of section 1128A(a)(5) to be no more than $10 per item, or $50 in the aggregate on an annual basis. 65 Fed. Reg. 24400, 24411 (April 26, 2000). Moreover, we theorized that "frequent rendering of items or services to any individual may preclude such items and services from being classified as nominal in value." Id. at 24407. However, many free transports, including many of those provided under the Arrangement, exceed the nominal value and local service limits.

Notwithstanding, for all of the following reasons, we will not subject Hospital X to civil monetary penalties under section 1128A(a)(5) of the Act in connection with the Arrangement:

There is either limited or no economical means of public transportation in the geographic area where Hospital X provides the free transportation services.
The free transportation services are not advertised and are available only to individuals who have already been referred to, or are being treated at, Hospital X.
The free transportation services are available only if there has been an individualized determination of need (i.e., the patient has no other regular and reliable means of transportation).
The free transportation services are available to all qualified patients who require a course of multiple treatments, subject to available resources. The Arrangement is not limited to, or targeted at, particular profitable treatments or patient populations.
The costs of the free transportation services will not be claimed directly or indirectly on any Federal health care program cost report or claim or otherwise shifted to any Federal health care program.
The geographic area within which the free transportation services are offered is limited to Hospital X's historic primary service area, the size of which is determined in part by its rural location, and other areas that include patients for whom Hospital X is the nearest provider of the prescribed treatments.
Consistent with Hospital X's not-for-profit mission, the Arrangement provides a benefit to the community by giving elderly and low-income Hospital X patients access to medically necessary, life-prolonging treatments that they may otherwise forego, in whole or in part, because of inadequate transportation.
C. Application of the Anti-Kickback Statute

The anti-kickback statute makes it a criminal offense knowingly and willfully to offer, pay, solicit, or receive any remuneration to induce referrals of items or services reimbursable by any Federal health care program. See section 1128B(b) of the Act. Specifically, the statute provides that:

Whoever knowingly and willfully offers or pays [or solicits or receives] any remuneration (including any kickback, bribe, or rebate) directly or indirectly, overtly or covertly, in cash or in kind to any person to induce such person -- to refer an individual to a person for the furnishing or arranging for the furnishing of any item or service for which payment may be made in whole or in part under a Federal health care program, or to purchase, lease, order, or arrange for or recommend purchasing, leasing, or ordering any good, facility, service, or item for which payment may be made in whole or in part under a Federal health care program, shall be guilty of a felony.

Id. Thus, where remuneration is paid purposefully to induce referrals of items or services for which payment may be made by a Federal health care program, the anti-kickback statute is violated. By its terms, the statute ascribes criminal liability to parties on both sides of an impermissible "kickback" transaction. For purposes of the anti-kickback statute, "remuneration" includes the transfer of anything of value, in cash or in-kind, directly or indirectly, covertly or overtly.

The statute has been interpreted to cover any arrangement where one purpose of the remuneration was to obtain money for the referral of services or to induce further referrals. United States v. Kats, 871 F.2d 105 (9th Cir. 1989); United States v. Greber, 760 F.2d 68 (3d Cir.), cert. denied, 474 U.S. 988 (1985). Violation of the statute constitutes a felony punishable by a maximum fine of $25,000, imprisonment up to five years, or both. Conviction will also lead to automatic exclusion from Federal health care programs, including Medicare and Medicaid. The OIG may also initiate administrative proceedings to exclude persons from Federal and State health care programs or to impose civil monetary penalties for fraud, kickbacks, and other prohibited activities under sections 1128(b)(7) and 1128A(a)(7) of the Act.

Remuneration from a hospital to a patient that is intended to induce the patient to obtain hospital services implicates the anti-kickback statute. For example, the routine waiver of Medicare Part B coinsurance -- a payment obligation required by Federal law -- implicates the anti-kickback statute, as would offers of cash or other valuable gifts that are intended to induce patients to order services paid for in whole or in part by a Federal health care program. Free transportation services offered by a hospital to Federal health care program beneficiaries may have monetary value and implicate the anti-kickback statute, if the requisite intent to induce self-referrals is present. Notwithstanding, in the instant case, for all of the reasons set forth above in the analysis of section 1128A(a)(5) of the Act, we will not subject Hospital X to sanctions for violations arising under the Federal anti-kickback statute in connection with the Arrangement.

III. CONCLUSION

For all of the above reasons, and based on the information provided, we conclude that: (i) the OIG will not impose a civil monetary penalty under section 1128A(a)(5) of the Act on Hospital X in connection with the Arrangement, as described and certified in your request letter and supplemental submissions; and (ii) the Arrangement could potentially generate prohibited remuneration under the anti-kickback statute if the requisite intent were present, but that the OIG will not subject Hospital X to sanctions for violations of the anti-kickback statute under sections 1128(b)(7) or 1128A(a)(7) of the Act in connection with the Arrangement, as described and certified in your request letter and supplemental submissions.

IV. LIMITATIONS

The limitations applicable to this opinion include the following:

This advisory opinion is issued only to Hospital X, who is the requestor of this opinion. This advisory opinion has no application, and cannot be relied upon, by any other individual or entity.
This advisory opinion may not be introduced into evidence in any matter involving an entity or individual that is not a requestor to this opinion.
This advisory opinion is applicable only to the statutory provisions specifically noted above. No opinion is herein expressed or implied with respect to the application of any other Federal, state, or local statute, rule, regulation, ordinance, or other law that may be applicable to the Arrangement.
This advisory opinion will not bind or obligate any agency other than the U.S. Department of Health and Human Services.
This advisory opinion is limited in scope to the specific arrangement described in this letter and has no applicability to other arrangements, even those which appear similar in nature or scope.
No opinion is expressed herein regarding the liability of any party under the False Claims Act or other legal authorities for any improper billing, claims submission, cost reporting, or related conduct.
This opinion is also subject to any additional limitations set forth at 42 C.F.R. Part 1008.

The OIG will not proceed against the Requestor with respect to any action that is part of the Arrangement taken in good faith reliance upon this advisory opinion as long as all of the material facts have been fully, completely, and accurately presented, and the Arrangement in practice comports with the information provided. The OIG reserves the right to reconsider the questions and issues raised in this advisory opinion and, where the public interest requires, rescind, modify or terminate this opinion. In the event that this advisory opinion is modified or terminated, the OIG will not proceed against the Requestor with respect to any action taken in good faith reliance upon this advisory opinion, where all of the relevant facts were fully, completely, and accurately presented and where such action was promptly discontinued upon notification of the modification or termination of this advisory opinion. An advisory opinion may be rescinded only if the relevant and material facts have not been fully, completely and accurately disclosed to the OIG.

Sincerely,

/s/

D. McCarty Thornton
Chief Counsel to the Inspector General

FOOTNOTES:

1. Because both the criminal and administrative sanctions related to the anti-kickback implications of the Arrangement are based on violations of the anti-kickback statute, the analysis for purposes of this advisory opinion is the same under both.

2. Providers offering transportation services to beneficiaries at a price that is below fair market

The Miami Herald reports that healthcare fraud is "massive" in South Florida. In the year ending Sept. 30, 245 defendants were charged with filing $793.5 million in false Medicare claims, according to U.S. Attorney R. Alexander Acosta.

This is indeed true. I have read a lot of news about groups that lay false claims and getting away with it. Farmville Secrets

Maybe Medicare premium increases could become permanently frozen--or even decreased? Maybe the nation's seniors and disabled, who rely on it for their health care, will no longer see premiums and copayments rise every year.

A new president looking for ways to fund a better health care system for Americans should take a hard look at increased policing of the Medicare system for fraud and inefficiency.
Easy Calm Program

FEDERAL JUDGE SAYS IF THEY DID NOT PROMISE OR SIGN ANYTHING 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.
MEDICARE FRAUD, MEDICADE FRAUD, AND KICKBACKS AND BRIBES BUSINESS AS USUAL,INSIDER INFORMATION GIVEN. 9B BS ONE THING BUT WHAT ABOUT YOUR "HANDS OFF POLICY" BY THE DOJ AND CMS AND HHS, AND WHY NO INVESTAGATIONS OR AUDITS TO CONFIRM OR HELP? "SELF DISCLOSURE BY CARRIER ANOTHER JOKE".

WHAT ABOUT "TAXPAYERS TO PREVENT AND STOP AND PREVENT FRAUD FOR MEDICARE AND MEDICADE" WHAT ABOUT WILLIS AND WILKINS BEING FIRED FOR NOT WANTING TO BREAK THE HEALTH FRAUD LAWS?

NJ CEPA CLAIM NOW ON FILE.....FALSE CLAIM UNDER APPEAL AND FILED..... WHERE WAS ANY HELP FROM YOUR DEPARTMENT?

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.

United States ex rel. Wilkins v. United Health Grp. Inc., No. 08-3425 (D.N.J. May 13, 2010).

FCA claim alleging aggressive marketing tactics by health plan provider dismissed
Publication: Health Law Week
Date: Friday, June 4 2010

The U.S. District Court for the District of New Jersey dismissed a qui tam action brought by two former employees of healthcare plan providers alleging violations of the False Claims Act (FCA) arising from excessively aggressive marketing methods. United Health Group Inc., a provider of access to healthcare services, had as its subsidiaries AmeriChoice and AmeriChoice of New Jersey, which each offered Medicare Advantage plans. Charles Wilkins and Darryl Willis (the relators), who were each employed by United Health Group and AmeriChoice, initiated a qui tam claim against United and its two subsidiaries under the FCA alleging numerous violations of Medicare and Medicaid regulations governing administration of the Medicare Advantage plans. The complaint alleged that the defendants engaged in unauthorized and aggressive sales methods in marketing the plans -- including the provision of illegal cash payments to providers to induce them to change beneficiaries to AmeriChoice and the provision of illegal kickbacks to doctors for obtaining the names of patients they could call and approach. The defendants moved to dismiss.

The district court concluded that the complaint failed to identify a single instance in which the defendants submitted a false claim to the government for payment as required to prosecute a qui tam claim as relators under the FCA. Under applicable federal appellate court precedent, the absence of such an allegation was fatal to the relator's false certification claim. The relators' theory of liability at base was that because United Health agreed that it would comply with all Centers for Medicare and Medicaid Services regulations, and because it was at times in violation of some regulations, it committed fraud each time it submitted a claim for payment. The district court concluded that this contention confused the conditions of participation in a Medicare or Medicaid program with the conditions of payment, and would open the door to a flood of tort claims of a type not contemplated by the FCA. Moreover, the complaint failed to allege that the violation of any regulation was actually relevant to any funding decision. As a result, the complaint failed to state a claim on which relief could be granted and, accordingly, the defendants' motion to dismiss was granted.

Source: Health Law Week, 06/04/2010

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These e-mail I send to Medicare Froud tip: HHSTips@oig.hhs.gov - 10/3/08 - never hada an answer.
My wife Jean Avellan (014-22 -4565-M) is dying and the doctor order for her a Hospice Nurse to take care of her.

When the medicine they send for her starting to arrived to our apartment (600 Canton Ave. Bldg. 2b Apt 2. Milton MA 02186). They came in a big envelope from FEDERAL EXPRESS. 3 envelopes at the time. Each had inside a small tube 1 oz. of Zinc Oxide 20% that I buy in CVS pharmacy for $3 or $4. For me that was very ad, that the pharmacy spend so much money in sending each small tube.

I started to look for the Pharmacy invoice, and I found a lot of discrepancy: Pharmacy EXCELLERX .

Hospice: Partner’s Hospice. Order #15064415. Rx 906737332 10/07/08 ZINC OXIDE 20% OINTEMT

$ 226.80.

RX 906737345 10/07/08 MAGIC BUTT PASTE $ 240.00 (it came in a plastic case about 6 onz. Made in the Pharmacy.) I look in the internet there is not “MAGIC” any thing. But the regular Butt Paste made by “BOURDREAUX” = Butt Paste Diaper Rash Ointment Jar of 16 oz. Cost $ 16.42.

Order # 15060218 again another MAGIC BUTT PASTE for $ 240.00 (but we only receive one)

Another zinc oxide for $226.80

Order # 15056630 Zinc Oxide 20% $ 226.80

Another MAGIC BUTT PASTE $ 240.00 (we only have one)

Order# 15026738 (Very Interesting) Zinc Oxide 20% $30.00 ???

Order # 15038935 (More Interesting) Zinc Oxide 20% $ 60.00 ???

We complained to the Social Worker of the Hospice, because the nurse attending my wife was very rude, and had very little compassion and bad bed side manners. They through my wife out of Hospice.

I call that pharmacy to see if my doctor could order some medicine for my wife; they said we only work with Hospice. ( ????)

I have all the invoices of the pharmacy here, if you want give me your fax number and I faxed to you.

Sincerely;

Manuel Avellan

600 Canton Ave. # 2-212

Milton MA 02186

617-696-9831

mavellan@comcast.net
My wife die December 27,2008