Compliance News Roundup: The Many Faces of False Claims Act Allegations

1. CMS and Its Claims Processing Contractors Issued Conflicting Guidance on the Proper Use of the KX Modifier for Part B Immunosuppressive Drug Claims - “Medicare Part B paid for some immunosuppressive drugs billed with the KX modifier that were not eligible for Part B payment. Of the 75 claims in our random sample, pharmacies had documentation to support the KX modifier for 65 claims but did not have support for the remaining 10.” Get the full scoop >>

2. Galena Biopharma Inc. to Pay More Than $7.55 Million to Resolve Alleged False Claims Related to Opioid Drug - “Galena Biopharma Inc. (Galena) will pay more than $7.55 million to resolve allegations under the civil False Claims Act that it paid kickbacks to doctors to induce them to prescribe its fentanyl-based drug Abstral, the Department of Justice announced today.

Given the dangers associated with opioids such as Abstral, it is imperative that prescriptions be based on a patient’s medical need rather than a doctor’s financial interests,” said Acting Assistant Attorney General Chad A. Readler of the Justice Department’s Civil Division. “The Department of Justice intends to vigorously pursue those who offer and receive illegal inducements that undermine the integrity of government health care programs.” Get the full scoop >>

3. Dr. Couch and Dr. Ruan Sentenced to 240 and 252 Months In Federal Prison For Running Massive Pill Mill - “Acting United States Attorney Steve Butler of the Southern District of Alabama, announces that Dr. John Patrick Couch and Dr. Xiulu Ruan were sentenced to 240 months and 252 months, respectively, in federal prison for running a massive pill mill in Mobile, Alabama.” Get the full scoop >>

4. Deeper Than the Headlines: The Many Faces of False Claims Act Allegations - When a lot of healthcare organizations consider their risk under the False Claims Act, they often think of coding and billing errors submitted on 1500s or UBs. It’s probably the first place I’d look for the greatest risk to a Medicare or Medicaid healthcare provider.  However, it’s important to not get complacent by only focusing on coding and billing error risks or errors. As a compliance officer, your compliance program should not only be considering the risk under direct claims submissions to government payors, but your program should also consider other financial transactions.

For example, the DOJ recently announced the CHRISTUS/St. Vincent Medical Center (Santa Fe, NM) settlement for $12.24 Million. This settlement resolved False Claims Act allegations, but the foundation of the allegations was that St. Vincent made illegal donations to county governments. The donations were used to fund the state share of Medicaid payments to the hospital as opposed to upcoding or unbundling of procedures on a 1500 or UB, which we often read about in other enforcement headlines. Get the full scoop >>

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