Re: Re: Medicare fraud, OR, Your future with Bubba

August 3, 2005

True, fines are mere slaps on the wrist, but a prison sentence is not. Even

30 months is not. But I would have preferred 5 years. Unfortunately, the

federal sentencing guidelines make it very difficult for judges to sentence

white collar offenders. If this guy had had an ounce of cocaine on him, he'd

be there for much longer.

GG

>

> PTS to a large fine, {$1,177,786} Wise to 30 months and a

> $6,000 fine, and Shirley Wallaceto 100 hours of community service.

>

> In my eyes that is a slap in the hand. There was a service in the RGV

> that ,rumor has it,that FBI hit them for fraud, a month later they

> change the name to something similar, and they are off running the

> streets again.

>

> With a slap in the hand like 100 hr of community service, people are

> not going to be afraid of taking a risk, there needs to be more

> punishment!

>

> > > For those of you who are thinking about " fixing " your patient

> care forms to

> > > make your patients eligible for Medicare reimbursement, or,

> worse, if you

> > > are

> > > doing it now, here's some light reading for you.D*$*$ This is

> the

> actual text

> > > of a

> > > Medicare fraud case from Arkansas.

> > >

> > > *

> > > -2-

> > > _______________

> > > Nos. 04-1373/1381

> > > _______________

> > > United States of America, *

> > > *

> > > Appellant/Cross-Appellee, **

> > > v. **

> > > Wise, *

> > > *

> > > Appellee/Cross-Appellant. *

> > > ___________

> > > Submitted: January 10, 2005

> > > Filed: July 5, 2005

> > > ___________

> > > Before LOKEN, Chief Judge, MORRIS SHEPPARD ARNOLD and MURPHY,

> > > Circuit Judges.

> > > ___________

> > > MURPHY, Circuit Judge.

> > > Patient Transfer Service, Inc. (PTS) and two of its employees

> were convicted

> > > by a jury for filing false Medicare and Medicaid claims. The

> district court

> > > sentenced

> > > PTS to a large fine, {$1,177,786} Wise to 30 months and a

> $6,000 fine,

> > > and Shirley Wallace

> > > to 100 hours of community service. PTS appeals its conviction and

> sentence.

> > > The

> > > government appeals the sentences of the employees, and on their

> cross

> > > appeals

> > > they

> > > appeal their convictions and sentences. We affirm in part and

> reverse in

> > > part.

> > > -3-

> > > I.

> > > PTS is an Arkansas company owned by Wise that provides

> ambulance

> > > transport services. Wise's brother, Wise, is a

> licensed

> > > paramedic who

> > > worked as the general manager of PTS. In that capacity Wise

> was in

> > > charge

> > > of all personnel and oversaw billing procedures. Shirley Wallace

> is the

> > > cousin of

> > > these two brothers, and she was the office manager and supervised

> the

> > > billing

> > > clerks

> > > who filed claims with Medicare and Medicaid.

> > > From January 1997 to March 1999, PTS filed 2,568 Medicare or

> Medicaid

> > > claims with identical coding. All of the claims related to the

> > > transportation

> > > of twelve

> > > individuals with end stage renal disorder. PTS transported them

> by ambulance

> > > from

> > > home to a dialysis treatment center and back. In advance of each

> transport

> > > Wallace

> > > prepared a transfer form which stated that the patient was

> confined to bed

> > > and could

> > > only be moved by stretcher to and from the hospital. The transfer

> form was

> > > given to

> > > the paramedics operating the ambulance, who would fill in

> information

> > > particular to

> > > the transport, such as the date, time, and crew names. After the

> patients

> > > were

> > > transported, the transfer forms would be routed to billing clerks

> to prepare

> > > claim

> > > forms for Medicare and Medicaid.

> > > The claim forms contain billing codes the ambulance provider had

> to fill out

> > > to describe the transport: Hospital Admit (yes or no); Type of

> Transport

> > > (initial trip,

> > > return trip, transfer trip, or round trip); Bed Confined - Before

> (yes or

> > > no); Bed

> > > Confined - After (yes or no); Moved by Stretcher (yes or no);

> Unconscious /

> > > Shock

> > > (yes or no); Emergency Situation (yes or no); Physical Restraints

> (yes or

> > > no); Visible

> > > Hemorrhaging (yes or no); Transported To / For (nearest facility,

> preferred

> > > physician,

> > > nearness of family members, or care of a specialist or

> availability of

> > > specialized

> > > equipment); and Medically Necessary (yes or no). In each of the

> claims at

> > > issue, the

> > > billing clerk at PTS marked " Y " for " yes " for the codes Bed

> Confined -

> > > Before, Bed

> > > -4-

> > > Confined - After, Moved by Stretcher, and Medically Necessary.

> PTS was

> > > reimbursed $841,276 on the basis of these 2,568 claims.

> > > The government investigated PTS and uncovered evidence that these

> patients

> > > had not been confined to bed, had not been moved by stretcher,

> and had not

> > > needed

> > > to be transported by ambulance. Medical personnel from the

> treatment centers

> > > testified that each of these twelve patients could have been

> transported to

> > > and from

> > > the centers by other means without endangering their health. The

> FBI

> > > videotaped

> > > several of the patients walking to or out of the ambulance and

> their home or

> > > treatment

> > > center without assistance. Paramedics testified that instead of

> being

> > > transported by

> > > stretchers, some of the twelve rode in the front seat of the

> ambulance or in

> > > the

> > > captain's chair (an individual seat behind the driver). One of

> the patients

> > > testified that

> > > statements on the claim forms indicating that she was confined to

> bed and

> > > needed a

> > > stretcher and ambulance transport were false. The husband of

> another patient

> > > gave

> > > similar testimony. There was additional evidence that the

> patients'

> > > activities were

> > > inconsistent with the descriptions on the claim forms. Some of

> them drove,

> > > cleaned

> > > house, gardened, bowled, and engaged in other active pursuits.

> > > The investigation also yielded evidence that the defendants knew

> that these

> > > twelve patients did not fit the descriptions on the claims. Both

> Wise

> > > and

> > > Wallace met a few of the patients in the PTS office, and Wise

> made some of

> > > the

> > > transports himself. Transfer forms were occasionally returned

> with notes

> > > from

> > > the

> > > paramedics indicating that family or friends picked up the

> patients from the

> > > treatment

> > > center, and some of the paramedics questioned Wise about

> the necessity

> > > of

> > > ambulance transport for patients who walked without assistance.

> Wise

> > > distributed a

> > > memo directing the paramedics to have all dialysis patients ride

> on

> > > stretchers and to

> > > take them into the treatment centers on stretchers. He also told

> paramedics

> > > and other

> > > employees that PTS had letters of medical necessity on file for

> the dialysis

> > > patients,

> > > but an FBI search uncovered no such letters relating to these

> twelve

> > > patients. One

> > > item discovered in the search was a note written by Wallace

> indicating that

> > > the

> > > -5-

> > > nephrologist treating Phyllis Warren, one of the patients, had

> advised that

> > > she did not

> > > need ambulance transport.

> > > The government also investigated two instances in which

> PTS " double hauled "

> > > by transporting two patients together in one ambulance and

> billing both

> > > accounts for

> > > the mileage. Neither were on stretchers; one patient rode in the

> front seat,

> > > and the

> > > other in the captain's chair. When the billing clerk at PTS

> noticed the

> > > coincidence of

> > > dates and times on the transfer forms, she asked Wallace and

> Wise how

> > > to

> > > prepare the claim forms because she did not believe the mileage

> could be

> > > reimbursed

> > > twice. She was nevertheless instructed to submit individual

> claims for each

> > > patient.

> > > The claim forms did not indicate that more than one patient had

> been

> > > transported, and

> > > each form claimed the full mileage for the trip.

> > > PTS, Wallace, Wise, and Wise were all charged with

> and

> > > acquitted of a conspiracy count that encompassed all 2,568

> claims. The jury

> > > convicted PTS of twenty two counts of aiding and abetting false

> or

> > > fraudulent

> > > claims

> > > involving Medicare, in violation of 18 U.S.C. D*$¡øD*$¡ø 2 and

287,

> and

> two counts

> > > of

> > > false

> > > statements involving Medicaid, in violation of 42 U.S.C. D*$¡ø

> 1320a-

> 7b.

> > > Wise

> > > was convicted of four counts of aiding and abetting false or

> fraudulent

> > > claims

> > > involving Medicare in connection with double hauling. Wallace was

> convicted

> > > of

> > > one count of aiding and abetting false or fraudulent claims

> involving

> > > Medicare in

> > > connection with the transport of Phyllis Warren. The court fined

> PTS

> > > $1,177,786,

> > > sentenced Wise to 30 months of imprisonment and a $6,000 fine,

> and Wallace

> > > to

> > > 100

> > > hours of community service in lieu of a fine.

> > >

> > > You can find the remainder of the 21 page opinion by putting in

> United

> > > States

> > > v. Patient Transfer Service, Inc., in Google, if you're

> interested in

> > > reading

> > > about the points on appeal.

> > >

> > > Wallace's sentence was upheld.D*$*$

> > >

> > > The Court remanded the case to the District Court to reconsider

> the fine

> > > based upon PTS's contention that it lacks the ability to pay the

> fine due to

> > > losses and legal fees resulting from the defense of this

> case.D*$*$ There is a

> > > complex

> > > system for setting fines, and the Court can either reduce the

> fine, reimpose

> > > it, or raise it based upon the further evidence it will hear on

> that

> > > subject.

> > > Be careful what you ask for.

> > >

> > > The government won its appeal that Wise's sentence is too

> lenient, and the

> > > Court will reconsider.D*$*$ It is quite likely that his 30

> month

> sentence could

> > > be

> > > increased.D*$*$ The sentencing Court gave him some credit for

> admitting guilt,

> > > which the Court of Appeals says the record does not

> support.D*$*$

> So he may

> > > well

> > > find his sentence enhanced.D*$*$ Either way,D*$*$ he'll get

> to meet

> Bubba.

> > >

> > > Gene G.

> > >

> > > E.(Gene) Gandy

> > > POB 1651

> > > Albany, TX 76430

> > > wegandy1938@a...

> > >

August 3, 2005

What is not mentioned in the penalties is that the provider will not be able to

have a Medicare or Medicaid provider number again, and that is more than half of

most ambulance company's business....so he is effectively out of business.

There's a big difference in " I got hit with an audit and had to repay money " ,

and " I got charged with intentional fraud and have a fine and jail time. " On

top of that, I've never seen an ambulance company that just happens to have

under 2 million sitting in the bank that he can fork out and have that money not

already earmarked for payroll, insurance, etc. If the company doesn't pay the

fine within 30 days, there is a hefty interest rate tacked on. For those who

think he can just open up under another name and be back in business......well,

several have tried that and wound up getting caught AGAIN.... and I can think of

one in San that tried that, three times and was busted each time.

That's not to say some haven's successfully skirted around and done it.....but

their names, or their spouses, better not be on any of the ownership documents,

and Medicare DOES check for that.

As for the medics that testified.....they would not be prosecuted because they

were essentially witnesses for the prosecution and the Feds want the

owners/managers that caused it to happen. Not only that, but most medics

haven't a clue about what is fraud and what is not, when it comes to the

guidelines for Medicare/Medicaid. They ASSUME their bosses/managers know what

they are doing. Some medics are getting wiser, but most are not.

I found it amazing that their billing manager (and I say that with tongue in

cheek), had the audacity of filling out run reports for the crews and then just

having the crews take them on the transport and put the date and times in.

THAT, I would have thought, would have at least had the crew have a feeling that

something wasn't right. However, a good many medics don't have a clue about who

to even call when they DO think something is wrong.....so they just go about

business as they are told. That is additionally true when some DO turn in a

company and a year later they see nothing is changing......so they assume all

was legal and above board since nobody did anything. What they don't realize is

that it takes a minimum of a year, and usually up to 3, for the Feds to get all

the evidence they need,.....in black and white, not just on hearsay.... before

they step in and effectively shut the doors and get the case before a grand jury

(I'm not sure which comes first, the grand jury or the arrests). The Feds are

real good at the " where there is smoke, there must be a fire " .....then going out

and finding the fire.

For those of you that don't know, it isn't just the ambulance companies and

other health care providers that get busted. Several years ago, a qui tam

action was brought against Blue Cross/Blue Shield of Illinois. They were the

Medicare Part B carrier for Illinois and Michigan, AND, the Medicare Part A

intermediary for the two states. Nine of their mid management people went to

prison......the fine was $245,000,000 (the highest fine ever levied against a

carrier)......and the woman who brought about the case, got 20% of that fine

(She was an employee of the carrier....although she was fired, before the case

went to trial).

Daphne

August 4, 2005

Joe,

How would this bill end up on their credit report? Banks don't take this

information into account, because they know in most cases that it is illegal

that this information was included in the credit report in the first place.

There is a BIG difference in items on a person’s credit report and failure to

pay just debt. EMS bills should never end up on the patient’s credit report.

If one of these bills does, the person whose report it ended up on has grounds

for a HUGE lawsuit against the provider that placed them there as well as

whatever else the FCRA allows.

Now, the real question is… Why can’t EMS decline a transport based on the

clinical evidence presented? I think at one time San Francisco was triaging in

the field. If they determined the transport was not necessary the patient was

given a bus token. When is an earache ever a medically necessary transport?

Why can’t the EMS crew assist grandma to the car for the ride to check her

bunion? EMS should then bill a “reasonable” amount for the assist $50 or so

should cover it.

I too have transported patients that were not medically necessary. Each

ambulance should have a credit card machine in it. If the transport is not

deemed medically necessary they should have to pay first. If they can’t or

won’t pay, they can’t ride.

Tater

joetemt_p wrote:

OK, here I go up on my soap box again..LOL. I DO agree that these

jokers should get everything that the government can throw at them

including the kitchen sink. Anybody that intentionally defrauds

medicare/medicaid like this should be hit with the BIG hammer. It's

theft, pure and simple. The ones they are really stealing from is

US. The honest people trying to do things the right way while they

line their pockets.

My main problem with the whole deal is what about the minor frauds

that steal services they aren't entitled to? I'm talking about the

ones that are on medicaid that call the ambulance at 0300 for a kid

that's had an ear ache for a week and is crying so much that Mama

can't sleep and says she has no other way to get to the hospital?

This isn't made up, I was on that run.

I work for a municipal service that's funded by the city and

county. As such, if they call and want to go, we have to haul em.

Natutally, the claim is denied, naturally they get a bill, naturally

they don't pay it. They know we can't refuse when they call, and

they know that if the only thing on their credit report is medical

bills, it doesn't go against them. Lending unstitutions don't even

take into account this type of non payment when considering a loan.

Until the PTB in Washington decide to make some changes, this type

of thing will continue to happen. I write honest reports. If

somebody walks to my rig, I put in that they walked and why. I do my

best to show why we should get paid for the run, but there are some

that you just can't without falsification and I refuse to do that.

Medicaid will pay a hospital for treatment of these folks, but WE

are left out in the cold. If medicaid deems there is no medical

necessity for an ambulance, they don't pay. Never mind the fact that

it costs every time you fire up a rig and make a run.

I have NEVER seen a case where something was done to individuals

for this type of abuse of the system. The PTB give excuses for not

changing things. If they do, people will be afraid to use the

system, kids and old folks won't get the care they need, etc, etc.

ad nauseum. Let you or me refuse to transport, and see who gets hit

with that BIG hammer. Never mind the fact that they weren't going to

pay anyway, the PTB will unload on us.

I'm not against medicaid by any means. The folks that need it

should have it, and they should be able to use our services as they

need them. What I AM against is the abusers. The ones that call the

ambulance to take Grandma to the hospital, and when you arrive there

are a dozen cars sitting around and the whole family in the house.

The ambulance got called because it's too much trouble for them to

wheel her to the car and lift her into the seat.

Until we get some changes, we'll continue to get runs that are

never paid and we'll continue to lose out. The PTB sit back in their

comfortable chairs and complain about the rising cost of health care

and do NOTHING to try and fix it (except cut funding and payments to

us honest folks).

An ambulance is just a money pit and a drain on the local economy

until YOU need it. An axiom that most politicians subscribe to.

I'll climb down now. Heights make me dizzy and I think I've used

about a quarters worth instead of my allocated 2 cents.

Thanks for listening to my ravings.

Joe Tollett

August 4, 2005

, you are wrong on one point......a patient or responsible party CAN be

sent to a collection agency for failure to pay an EMS bill that was their

legitimate responsibility to pay......and that would go on a credit report.

And, that includes bills denied by Medicare or Insurance as non-medically

necessary or non-covered. For Medicaid, it depends on the state....and in most

states, if the denial is for non-covered services, the patient owes the bill.

In Texas, the patient has to have signed a waiver, in order for a Medicaid

patient to be sent a bill or to collections.

Daphne

-------------- Original message from " E. Tate " :

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