|McALLEN, June 24 - A recent two-day conference allowed hundreds of Rio Grande Valley healthcare professionals to discuss in-depth whether the perception of fraud in their industry is justified.
Jon Scepanski is chief operating officer for Apex Primary Care, a home health company based in Edinburg. He said for every one bad actor in the healthcare industry in the Valley there are dozens and dozens more doing a good job for the community.
Scepanski attended the Rio Grande Valley Healthcare Fraud and Compliance Conference held at the McAllen Convention Center last week. He said he learned a lot from the conference.
“There is fraud and abuse, but there is fraud and abuse in every area. I know everyone here, especially at this conference, wants to resolve it and take care of it, they want to be proactive about it,” Scepanski said.
“From what I have noticed there are a lot of people doing a lot of good here that do not get talked about – it is no different to the news and all the terrible things that are happening are reported on. There are a lot of people doing a lot of good things.”
Scepanski outlined some of the things happening in his industry which help society as a whole.
“The industry we are in, the healthcare industry, the home health industry, primary home care, these are cost-containment programs. These are preventative programs to keep people out of the hospital. So, what we are doing in reality is saving tax dollars,” Scepanski said.
“We are keeping people out of the more expensive institutions. We are keeping them in their own home, where they are paying their own electricity, where they are paying their own taxes. We are doing more good than we are bad. However, it is just the bad that is getting exposed and talked about and talked about. I do not agree with this. I do not think it is fair. We should take pride in the industry we are in.”
Scepanski said because rules and regulations in the healthcare industry are changing fast, a conference that focuses on fraud and compliance is to be welcomed. “We could have been here for two days talking about all the great things that are happening in healthcare. But, we were here to get educated. This (perception of fraud) is a black cloud and black eye on the industry. Yes, there is fraud and we want to squeeze out those who are doing that. That is continuing to happen and it will happen at a faster pace when we are all educated,” he said.
Scepanski likened the healthcare fraud issue in the Valley to the big BP Deepwater Horizon oil spill in the Gulf of Mexico. “BP said here is our plan of correction, this is what we are doing in the community, this is what we are giving back to the community; we are caring about the environment. I think we need to have a campaign about the home health industry and how strong it is because when these baby boomers retire, guess what, we have to figure out a way of keeping them out of the hospital,” Scepanski said.
Jake Fuller is a consultant in the healthcare industry based in the Valley. His work includes promoting the Border Health Caucus, which represents physicians from Brownsville to El Paso. Like Scepanski, Fuller attended the Rio Grande Valley Healthcare Fraud and Compliance conference, which was held at the McAllen Convention Center last Tuesday and Wednesday. Fuller said he did not like McAllen being referred to as the No. 2 area in the nation for healthcare fraud.
“There is a problem but it is being painted with a broad brush. When you get down in the weeds and you start looking at various statistics, you do not come up with the assessment that McAllen or the Valley is No. 2 in the nation in fraud. What you will find is that we are a very poor area that still has a healthcare physician shortage and in some areas we have maybe an abundance of healthcare providers,” Fuller said.
Fuller said the fraud and compliance conference, which was put on by Senior Community Outreach Services, Inc., was an excellent event. He said Valley healthcare providers clearly have to understand that they must be in compliance with the law.
“However, to suggest that we are the worst in Texas for fraud, much less the rest of the entire nation is an affront. It is an insult to a number of hard working, overwrought, over-burdened healthcare providers,” Fuller said. “I resent being labeled No. 2 in the nation. It is impossible. There might be slivers of areas we are No. 2 but no more than that. They (fraud investigators) go for the border and the Valley because the perception among many healthcare agencies is that it is low hanging fruit and we can catch you pretty quickly because you ain’t that smart.”
One of the speakers at the conference who cited McAllen as being No. 2 in the nation for healthcare fraud was Michael E. Garcia, a special agent with the U.S. Department of Health & Human Services-Office of Inspector General. Garcia said HHS-IOG opened an office in McAllen in 2010 precisely because the area was No. 2 in the nation for healthcare fraud. He said Florida was No. 1.
Garcia presented a power point which showed fraud in various sectors of the healthcare industry, including home health, durable medical equipment (DME), and ambulance companies.
With regard to home health agencies, Garcia said fraud can happen by billing for medically unnecessary services, billing for services not rendered, forging doctor’s signatures on 485s; paying kickbacks to doctors for referrals, and paying kickbacks to beneficiaries.
With regard to ambulance companies, Garcia said fraud can occur through billing for a higher level of transport than was actually provided, by ghost transports, by forging physician signatures for authorization, by medically unnecessary transports, and by double loading.
Garcia had a slide in his power point titled, “Ways to Catch the Interest of OIG.” He listed some of the ways this can happen: Charge the trip to Las Vegas on your Medicare Cost Report; bill for having personally provided 41 one hour psychotherapy services in a day; provide speech therapy to comatose patients; provide office consultations and follow-up visits to deceased patients; home health agency or DME company purchasing a sports car for a doctor.
Garcia provided examples of healthcare fraud in the Valley. He referenced United DME of Weslaco, which was owned by Juan De Leon. Garcia said De Leon billed for power wheelchairs that were never delivered, provided patients with less expensive scooters, and billed for power wheelchairs on deceased patients. Garcia said De Leon is currently serving a ten year prison sentence.
Garcia also referenced ACE Medical Equipment of Palmview and its owners, Velma and Valente Alaniz. Garcia said the company delivered less expensive scooters, billed for power wheelchairs that were not delivered, and forged doctor’s signatures on physician orders. He said Velma Alaniz is serving two years in prison and Valente Alaniz is serving three.
Garcia also focused on RP Best Choice of McAllen and its owner, Pedro Perez. “If anybody knows Pedro Perez, or where he is, please let me know,” Garcia said. There was laughter among some in the audience.
Garcia said Perez opened a “false front” DME operation in north McAllen and billed for beneficiaries out of Miami, Florida. He said Perez also billed for collagen dressing, for which Medicare pays $6,000, and used local doctors’ NPI numbers as a referral for billing. Garcia said NPI numbers can be obtained on the Internet. He said Perez billed Medicare for $1.2 million over an eight month period and was able to collect reimbursements totaling $600,000. He said Perez has been indicted on eight counts of health care fraud and two counts of aggravated identity theft. Garcia said Perez is currently a fugitive and on the OIG’s most wanted list.
Garcia then ran through some of the OIG’s accomplishments. He said that in fiscal year 2012, OIG investigations resulted in approximately 723 criminal convictions; resulted in over 382 civil actions; resulted in the banning of 2,662 individuals and entities from Medicare, Medicaid, and other federal health care programs; and returned $4.6 billion back to health care programs.
Garcia also said the federal government was right to strip Hidalgo County of its “Medically Underserved Area” designation in Jan. 2012. He said such a designation meant more money for area physicians. He said that in 2011, Hidalgo County had 830 licensed physicians, 156 licensed physician assistants; 18 nursing homes with 2,049 licensed beds, 93 pharmacies, 248 home health care agencies, 302 durable medical equipment services, 21 diagnostic imaging centers, 19 kidney dialysis centers, 62 ambulance services.
Fuller, the healthcare consultant, said the government was wrong to strip the “Medically Underserved Area” designation from Hidalgo County. “The fact that we are no longer a MUA is a travesty,” Fuller said. “We are the poorest county in the United States and Cameron is in the top five. To suggest we have enough physicians is just not accurate. Maybe we have enough physicians in McAllen, but do we have enough physicians in La Joya, or Hidalgo, or Palmview or Edcouch-Elsa? Many communities do not have enough access to care. It remains a critical area for the Border Health Caucus. We do not have enough hospitals. The beds are crowded during the flu season. Overall, it is just not true,” Fuller said, in response to Garcia’s presentation.
Senior Community Outreach Services, Inc., the non-profit which organized the RGV Healthcare Fraud and Compliance conference, is funded by the National Hispanic Council on Aging. Its director of programs, Rachanna Rodriguez, said that while the organization has been around for 38 years, serving Willacy, Cameron and Hidalgo counties, this was the first time it had put on a fraud and compliance conference.
“It was quite an undertaking given that we have become the second most notorious area in the nation for healthcare fraud. Through this event we want to empower our providers and to take a more active approach to putting an end to healthcare fraud. We need to do everything we can to help preserve and protect the trust funds for our seniors,” Rodriguez said.
Rodriguez said the time was right to hold a fraud and compliance conference “because of the amount of healthcare fraud cases that are being reported on a day-to-day basis, not only by Medicare beneficiaries but by healthcare professionals themselves.” She said she was pleased with the turnout.
“We here in Valley have a tarnished image. We know we have a high rate of healthcare fraud and abuse here. We hear from providers on a day-to-day basis and how they practice in the grey areas and those grey areas are what cause those individuals to become subject of healthcare fraud,” Rodriguez said.
“We have seen an increase in DME, home health, providers’ fraud, hospital fraud, violations of patients’ rights. This is very important because it is the patients who have the right to choose their medical provider. On a day-to-day basis we hear from 20 to 30 seniors who tell us, I did not get the healthcare provider of my choice, what can I do?”
Rodriguez said according to the U.S. government, the McAllen area has “become the second most notorious area in the nation for healthcare fraud, next to Miami-Dade, Florida.” She said the Valley needs more “good” healthcare providers because it has a large Medicare population which needs access to affordable healthcare.
Asked if she had learned at the conference of any new ways healthcare fraud is being committed, Rodriguez said: “The conference has reaffirmed what we already knew. There are patient rights violations, kickbacks and bribes, and illegal marketing practices. The home health agencies by a show of hands said they have been adversely affected by losing patients to a competitor because of the illegal marketing practices. It is disconcerting because no one is thinking of the patient. It is the patient who deserves quality care. It is the patient we need to advocate for, not our own bottom lines. At the end of the day, our responsibility as healthcare providers is to provide quality care.”
Jeff Drummond, an attorney with Dallas-based Jackson Walker, LLP, spoke at the fraud and compliance conference. He said he does not have any personal experience of healthcare fraud in the Valley. However, he said the question and answer sessions were somewhat revealing,
“It certainly seems to be pretty universally understood that that is the case, that there is a lot more (fraud) that goes on down here. And certainly, listening to some of the questions being asked in some of the sessions, people are telling us there is a lot more stuff going on here that, if it were going on in Dallas, people would be pretty shocked by,” Drummond said.
“Here, everybody is talking about everybody else doing it. When you listen to the questions being asked that gives you a good clue. When they say, ‘well, I know another practice that is doing this, and I know another group is doing this,’ then you get an idea that, as least as far as they are concerned, that is what the universe looks like. When someone says this and everybody else nods, you know that is the mindset in the area.”