As we reflect on 2016, we wanted to provide a list of the top exclusions of the year, as examples of what the Office of Inspector General (OIG) and State Medicaid governing bodies are looking for in their audits.
These are good lessons for all and range geographically from Puerto Rico to Wisconsin, and cover actions ranging from false claims to improper telemarketing.
If you ever have any questions or concerns, about best practices or your employees, please send us an email or give us a call.
1. Permanent exclusion
Date excluded: September 7, 2016
Entity Name: Oxford Diabetic Supply, Inc. (Oxford),
Entity category: Durable Medical equipment (DME) supplier
State: New Jersey
Offence: The Entity solicited for sales by making calls to Medicare beneficiaries and then billed Medicare for the sale of the equipment. This offence violates telemarketing provisions set by the Social Security Act, regarding supply of DME
2. Permanent exclusion
Date excluded: January 5, 2016
Entity name: American Therapeutic Corporation, American Sleep Institute, and MedLink Professional Management (collectively, “the practices”)
Entity category: Therapy providers
- Paid kickbacks to facilities for assisted living to refer individuals for treatment
- Claimed payments for services that are considered medically unnecessary
- Falsification of documents in order to be reimbursed for medicare
3. Excluded for 30 years
Date excluded: May 5, 2016,
Individual’s name: Eugene A. Fox, D.P.M.
Offence: Billed Medicare for podiatry services that he did not render or that were rendered by unqualified employees.
4. Excluded for 15 years
Date excluded: June 10, 2016
Individual’s name: Mark Goff
Category: Hospital owner and manager
Offence: He influenced the hospital to submit fraudulent claims for provision of outpatient psychiatric services.
5. Excluded for 10 years
Date excluded: June 9, 2016
Individual’s name: Alan Balkansky
Offence: False Claims submission for:
- Provision of physical therapy by unqualified persons.
- Services that had not been rendered
- Services provided to people who did not qualify for medicare
- Services that did not meet medicare documentation requirements
6. Excluded for 10 years
Date excluded: September 1, 2016
Individual’s name: Delano H. Webb, MD,
State: West Virginia
- Provided suppliers of Durable Medical Equipment(DME) with signed blank prescriptions and certificates of Medical Necessity that were incomplete. The prescriptions and certificates, which the suppliers used for making false claims, purported to show that diagnosis had been made and the equipment ruled a necessity, while in fact, it had not.
- Obstruction of the ongoing investigation against him by resigning fraudulent prescriptions and inserting them in patients’ medical files in order to avoid repaying Medicare/Medicaid for false claims already made.
7. Length of exclusion: 10 years
Date excluded: August 19, 2016
Entity Name: John Balko & Associates, Inc. d/b/a Senior Healthcare Associates (SHA),
Entity category: Audiology Practice
Offence: Submission of claims to medicare for procedures that were not medically necessary, that patients did not authorize or did not reflect in patients’ medical records.
8. Length of exclusion: 7 years
Date excluded: July 26, 2016
Individual/Entity: Entity and owner
Entity and Individual’s name: Nexus Medical Services, Inc. (Nexus), and, French McClung (McClung), the owner
Category: Drug Testing Laboratory
- Employing a person who is excluded from federal health care programs
- Paying kickbacks disguised as monthly rent to a physician who was supposed to refer his patients to Nexus in exchange for Nexus subletting the physician’s office space.
9. Length of exclusion: 5 years and a settlement of $100,000
Date excluded: September 19th 2016
Individual’s name: Susan Toy
Category: Medical Biller
State: New Jersey
Offence: Prepared false claims and made submissions for obstetrics and gynecology services not rendered.
10. Length of exclusion: 5 years
Date excluded: September 6, 2016
Individual’s name: Narciso Reyes Carrillo, MD
State: Puerto Rico
Offence: By providing healthcare services to Medicare patients while under exclusion, the physician caused Medicare to be billed for false claims