#Kentucky’s Office of Medicaid Fraud and Abuse

[dontmeantobepoliticalbut]

When Kentucky Attorney General turned Republican gubernatorial candidate Daniel Cameron discovered that an elected state Judge had accepted a campaign contribution of $250 from an attorney in a case before him last month, Cameron cited the donation as a reason that the judge had to recuse.

“These facts, individually and together, could cause a reasonable observer to question the impartiality or bias of the presiding Judge,” Cameron said.

But previously unreported public records information obtained by The Daily Beast shows that Cameron was in the same position at the same time—he just never acknowledged it.

In March and April, Cameron accepted $6,900 from officials at an addiction recovery center tied to an ongoing state investigation. Despite the donations, Cameron did not recuse himself from that investigation before he attacked the Judge. Instead, he waited until an open records request threatened to reveal the existence of that investigation, personally withdrawing from the case two days after the request came in.

The full timeline of events raises questions about Cameron’s conflict of interest, what he knew, and when. It will also almost certainly add fuel to bipartisan accusations that the outspoken, politically polarizing, Trump-supporting Republican has abused the power of his office during his tenure.

The company in question is Edgewater Recovery Center, a Kentucky-based addiction resource provider. According to the open records correspondence obtained by The Daily Beast, Edgewater is currently party to an investigation run by Kentucky’s Office of Medicaid Fraud and Abuse, a division of the Office of Attorney General. The Cameron donors include Edgewater’s owner, its general counsel, and directors for the recovery center’s medical, human resources, and clinical practices.

No Edgewater employee has given to Cameron previously, Kentucky campaign finance records show. And the donations appear to have come in the late stages of the investigation, which was opened sometime in 2022, according to a public records response obtained by The Daily Beast.

The donations all came in March and April, per state campaign finance records. But Cameron only recused himself from the investigation on May 19—those two days after his office received a May 17 request for a list of his recusals, and one week after his conflict-of-interest broadside against the Judge. It then took another week for Cameron’s office to answer the request, which included a copy of Cameron’s notice of recusal, dated May 19. To explain the recusal, Cameron’s office cited “an abundance of caution.”

But the recusal came three days after Cameron won the GOP primary, which the donations were designated to support, according to state campaign finance filings. (The Judge he’d attacked earlier that month was eventually removed, but not for the political donation—he had also “liked” a political post on Facebook in support of Democratic Gov. Andy Beshear.)

Additionally, records reviewed by The Daily Beast show that while Cameron recused himself from other cases in the time after receiving the Edgewater donations, he didn’t recuse from that case until the public records inquiry.

The campaign eventually returned the money from Edgewater donors on June 14, campaign finance filings show—nearly a full month after winning the primary election that the donations helped fund. But those refunds came five days after Cameron’s office received a follow-up request for more details about the probe. The OAG didn’t reply to that June 9 request until June 16—two days after the Cameron campaign issued the refunds.

According to the public records information, the Edgewater donations appear to have come late in the probe, after the OAG had already completed extensive investigative work and was contemplating punitive action.

In its response to the records request, the office claimed that the case file was exempt from public disclosure because the release might “harm an ongoing criminal investigation.” The reply also cited “information to be used in a prospective law enforcement action or administrative adjudication” and “documents prepared for or in anticipation of [criminal] litigation or a trial.”

The OAG noted that the withheld information includes witness interviews, subpoenas, correspondence with Medicare Managed Entities, financial information, and documents still under court seal.

The case number indicates that Cameron’s office opened the probe sometime in 2022. It is not immediately clear whether any Edgewater officials are targets. Edgewater did not immediately reply to an emailed request for comment. Neither Cameron’s office nor his campaign replied either.

This wouldn’t be the first ethical quandary Cameron has faced while running Kentucky’s law enforcement operations. Cameron first drew national attention—and condemnation—after he defended the “no-knock” police shooting death of Breonna Taylor in 2020, calling the killing “justified.”

But the Edgewater investigation wouldn’t even be the first ethics dilemma tied to Cameron's campaign contributions this year.

In April, Cameron’s campaign and office defended a combined $100,000 in political donations from a gaming company that is currently suing the state, with Cameron named as one defendant.

The money came from gaming company Pace-O-Matic and two of its executives, and it went to a PAC backing Cameron’s campaign, called “Bluegrass Freedom Action,” the Louisville Courier-Journal reported at the time. Pace-O-Matic had just spent months throwing cash at lobbyists, seemingly in a failed attempt to ply the Kentucky legislature to block a bill that would have restricted its gambling activity in the state.

When the bill passed, Pace-O-Matic sued the state. The $100,000 gift to the pro-Cameron PAC came in the weeks after the bill was blocked and before the company filed the lawsuit. Additionally, Pace-O-Matic executives and their family members—16 people in all—also gave nearly $30,000 directly to Cameron’s campaign, according to the Courier-Journal. All 16 contributions came on March 27—the day before the company filed its lawsuit.

The donations prompted a lawyer and donor to Cameron’s primary opponent, Kelly Craft, to file an ethics complaint. But Pace-O-Matic, the Attorney General’s office, and Cameron all rejected suggestions of impropriety.

“In this specific instance, the Attorney General’s office has already been defending the legislation passed by the General Assembly. No matter who asks, he does the same thing, which is that he will stand up for what’s right and defend the laws of Kentucky,” Cameron's gubernatorial campaign manager Gus Herbert said in a statement at the time.

Last year, Kentucky Democrats alleged that Cameron violated state ethics rules when he announced his gubernatorial campaign while his office investigated sitting Democratic Gov. Andy Beshears. An ethics complaint at the time cited rulings that prohibit the Attorney General from investigating a sitting Governor. (In January, Cameron’s office ruled that Beshears had violated open records laws by withholding information related to school closures during the COVID pandemic.)

But Cameron, who denied wrongdoing in that matter, has also cried foul when it comes to investigations against Republicans. This month, he attacked the federal indictment against ally Donald Trump, saying that “Kentuckians continue to be concerned about the political weaponization of government power.”

Other ethics concerns linger among Democrats. This Thursday, the Cameron campaign lashed out at a political ad attacking him for his connections to efforts to score controversial pardons from former GOP Gov. Matt Bevin, who in his final months in office issued pardons to people convicted of grisly crimes, including murder and rape.

While Cameron initially vowed to investigate the pardon scandal, he handed it off to the FBI. He later hired two top officials who advocated for controversial pardons while working in Bevin’s office.

Cameron also has donor ties to another major player in Kentucky GOP politics who pushed Bevin to pardon a friend of his. That megadonor—Kentucky financial and nursing home magnate Terry Forcht, a longtime ally of Senate Minority Leader Mitch McConnell—contributed to Bevin while advocating for the pardon of the son of a Forcht family friend.

But the Forcht family also donated to Cameron himself—in 2019, according to state filings.

Earlier this month, Cameron was photographed meeting personally with the Republican financier at Forcht’s office.

[prelawland]

60 Medical Professionals Charged With Illegally Prescribing Opioids

By Sabrina Martins, Roger Williams University Class of 2020

April 29, 2019

With the opioid crisis on the rise, there have been major changes in law enforcement’s effort to handle it, especially in Appalachia region which spans from northern Mississippi to western New York. One way that there are combating the crisis in that area is the creation of the Appalachian Regional Prescription Strike Force, also known as the ARPO Strike Force, that was created last year. Partnered with the Centers for Disease Control, Department of Health and Human Services, and local public health offices to charge 60 individuals with several charges for illegally providing opioids [4]. Charges range from unlawful distribution of controlled substances to conspiracy to obtain controlled substances by fraud [3]. The penalty for these charges can vary depending on the amount and the DEA schedule of the controlled substance prescribed [5].

After analyzing databases and identify suspicious prescribing activity the Department of Justice found that the case involved over 350,000 illegal prescriptions of controlled substances [3]. Most controlled substances are illegal in the United States due to their lack of medical benefit and its potential addictiveness, like heroin and LSD. However, the control substances that must be prescribed by a licensed medical professional, like morphine, do have a proven medical effect that efficiently benefit patients. Nonetheless, the Drug Enforcement Administration, DEA, have placed all controlled substances in different schedules or lists based on potential for medical use,potential for abuse, and dependence liability[6].

Out of the 60 individuals arrested in the bust, 31 of them were doctors. Though each one other the doctors had different reasons or methods for their illegal prescribing. One doctor prescribed for their own personal use, whereas another got bribes from a local pharmacy for prescribing specific drugs, like opioids [2]. Some doctors would pre-sign blank prescriptions and then hand them off to employees to fill out the rest. Another doctor from Kentucky would use Facebook to sell opioids. Then Facebook users would meet up with the doctor at his house to pick up the prescription to fill at a pharmacy of their choosing [3]. In Tennessee, a doctor that branded himself as the “Rock Doc”, would trade controlled substance prescriptions for sexual favors. Over the course of 3 years, the “Rock Doc” prescribed about 1.5 million opioid and benzodiazepines [1].

This illegal opioid prescribing bust marks another success for the ARPO Strike Force and reveals that there is a great need for more law enforcement departments similar to it. For example, the Department of Human and Health Services reports that since July 2017, the DEA has issues 31 immediate suspension orders, 129 orders to show cause of prescription, and received over 1,300 surrenders to the Controlled Substance Act that places drugs into schedules. Similarly, since June 2018, 2,000 individuals, including 650 providers, have been excluded from Medicare, Medicaid, and all other federal health care programs for opioid diversion and abuse [4].The APRO has impressed several government officials, they do not plan on slowing down their efforts in ending the opioid epidemic. Despite the department’s recent creation, they will be expanding into the western district of Virginia [4].

________________________________________________________________

[1] https://www.cnn.com/2019/04/17/politics/justice-department-health-human-services-doctors-charged-opioids/index.html

[2] https://www.usnews.com/news/health-news/articles/2019-04-17/doj-charges-dozens-of-health-workers-with-handing-out-opioids-for-money-sex

[3] https://www.cnbc.com/2019/04/17/60-doctors-charged-for-illegally-dispensing-painkillers.html

[4] https://www.justice.gov/opa/pr/appalachian-regional-prescription-opioid-arpo-strike-force-takedown-results-charges-against

[5] https://criminal.findlaw.com/criminal-charges/what-is-a-controlled-substance.html

[6] https://www.dea.gov/controlled-substances-act

Photo Credit: GeoTrinity

[ericfruits]

Why cutting even wasteful spending is so hard

HE WAS known as “Mr Social Security”. Eric Conn, a disability lawyer fromPikeville, Kentucky, gained notoriety in his impoverished part of Appalachia for his ubiquitous billboards and flashy TV commercials, which featured Rolls-Royces, beauty queens and a 19-foot replica of the Lincoln Memorial. But what earned Mr Conn his nickname was his uncanny ability to secure Social Security payouts for nearly 100% of his clients. Mr Conn’s luck has since run out. In March, the 56-year-old lawyer pleaded guilty to defrauding the government of $550m in federal disability benefits, the largest case of Social Security fraud in the country’s history.

Although scams like these outrage lawmakers and taxpayers alike, they represent just a small fraction of the billions in excessive, unnecessary and illegal payments made by the federal government. In the past decade these improper payments have increased by more than 250% (see chart). Donald Trump has vowed to cut them in half over ten years. Past efforts suggest that doing so will not be easy. In 2010, Barack Obama vowed to reduce wasteful, fraudulent and abusive payments by $50bn. Nine years earlier George W. Bush set a goal of eliminating them entirely. Neither president succeeded.

The federal government doles out $3.1trn every year, not far short of Germany’s annual GDP. Most of these funds are disbursed without a hitch. But when payments are made to the wrong person, in the wrong amount, or with invalid documentation, they are deemed “improper”. According to the Government Accountability Office (GAO), a congressional watchdog, such payments totalled $144bn in 2016, nearly four cents out of every federal dollar spent. Many of these payments are legitimate: missing paperwork does not necessarily denote an undeserving recipient, and underpayments as well as overpayments can be deemed improper. But a portion is fraudulent. Deloitte, a consulting firm, reckons it could be as much as a third.

Agencies that spend large sums of money with little scrutiny are particularly vulnerable. Medicare, the public-health programme for the elderly, processes 1.2bn medical claims each year, collectively worth over $600bn. Medicaid, the health-insurance scheme for the poor, pays out another $350bn. To ensure patients receive treatment in a timely fashion, both programmes are required to pay doctors, hospitals and other health-care providers within 30 days. Handling such an enormous volume of transactions requires automated systems designed for speed and efficiency, not accuracy. Fraudulent claims often go undetected. In 2016, 10% of Medicare and Medicaid outlays, equal to $96bn, were spent on services that were not delivered, were unnecessary or were otherwise erroneous.

Programmes that rely on self-reported, unverified information are also susceptible to fraud and waste. In 2016 the earned-income tax credit (EITC), a wage subsidy for low-income workers, paid out $67bn in refunds to 27m taxpayers. Whereas EITC benefits come out of the Treasury’s coffers, eligibility for the tax benefit—which is based on income and a number of other variables—is determined by taxpayers themselves and cannot easily be verified. The IRS is not allowed to correct erroneous EITC claims automatically and it lacks the resources to audit more than a small fraction of households that receive the benefit. As a result, the IRS estimates that in 2016 nearly a quarter of all EITC payments, totalling $17bn, were issued improperly.

Many of the incentives that dictate how the government spends federal tax dollars tend not to prevent fraud and waste but to encourage it. The private contractors employed to pay the government’s health-care bills are under pressure to process claims as quickly and inexpensively as possible. As Malcolm Sparrow of Harvard’s Kennedy School of Government points out, “The cheapest way to process a claim is to pay it without question.” Lawmakers are reluctant to boost spending on fraud investigation and enforcement—despite returns on investment as high as 500%—for fear that such measures might delay legitimate payments to providers or beneficiaries. “They want to get benefits out the door,” says Beryl Davis, the GAO’s director of financial management.

Officials say they are getting cleverer at reducing wasteful spending, and are moving away from a “pay-and-chase” model, in which auditors scramble to recover money spent on fraudulent claims, towards one that prevents such payments from being made in the first place (which is what credit-card issuers do). In 2012 the Centres for Medicare and Medicaid Services (CMS), the agency that administers America’s two public health-care schemes, spent $40m on software that screens and verifies health-care providers, using thousands of private and public databases. The year before the agency shelled out another $77m on a fraud-detection system that scans real-time claims data for suspicious billing patterns, and flags those most likely to be fraudulent. The Office of Management and Budget has a “Do Not Pay List” to help agencies verify the eligibility of firms and individuals before sending them money. The results have been underwhelming. The new CMS screening tool was supposed to keep illegitimate providers out of the system, but the GAO estimates that more than one in five Medicare providers lacks a valid address; nearly one in ten is based out of the equivalent of a UPS store.

As for Mr Conn, the lawyer, he slipped away from house arrest on June 2nd; his ankle tag was found in a backpack by the Interstate 75 near Lexington, Kentucky. He remains at large.

This article appeared in the United States section of the print edition under the headline "An improper mess"

http://ift.tt/2sYXGjo

[omcik-blog]

New Post has been published on OmCik

New Post has been published on http://omcik.com/cms-draft-attracts-few-enrollment-abuse-stories/

CMS draft attracts few enrollment abuse stories

Insurers see the calendar as one of their few remaining defenses against health risk. (Photo: Thinkstock)

Health insurers and health insurance agents may have a few stories to tell about health insurance special enrollment period fraud, but not all that many they want to share with the government.

The Centers for Medicare & Medicaid Services recently included tougher SEP verification rules in a new package of draft regulations. CMS officials say they hope the regulations will help stabilize the individual major medical market, and persuade insurers to stay in the market for the rest of this year and all of 2018.

Related: ACA exchange team hopes to delay filing dates

CMS added the SEP rules in response to complaints from insurance company executives and others that some consumers are gaming the system, by using loopholes in the SEP rules and the SEP verification process to wait until they get sick to pay for coverage.

Many insurers and insurer groups have submitted comments praising the new SEP verification rules, but a scan of the 4,017 comments submitted suggests that only a few comments from insurers and agents mention first-hand encounters with individual health enrollment problems.

The ACA eliminated most of the defenses health insurers once used to manage health risk. One of the few defenses insurers can still use is to allow easy access to health coverage only during a limited open enrollment period. (The open enrollment period for 2017 ran from Nov. 1 through Jan. 31.)

Consumers who want to buy individual major medical coverage at other times of the year are supposed to show they have a good excuse, such as loss of access to employer-sponsored coverage, to qualify for a SEP.

The idea is that healthy consumers will shrug and buy coverage during the open enrollment period, for fear of getting sick or hurt and running up big bills during other times of the year, when they can’t buy health coverage.

But health insurers have reported seeing signs that consumers have been defeating even that flimsy defense, by lying about whether or not they qualify for SEPs. Some insurers have suggested that claims for SEP enrollees are much higher than claims for other enrollees. CMS responded has responded by proposing a number of changes in SEP rules, such a requirement that all SEP applicants provide some kind of documentation for SEP requests.

Many patients, patient advocacy groups and provider groups have questioned whether SEP abuse is common. The American Cancer Society Cancer Action Network and Consumers Union are just two groups that have asked for evidence documenting that SEP abuse is common.

Just how devious are SEP applicants? For the CMS regulation drafters, that may still be an open question. (Image: Thinkstock)

The comments

“SEP-qualifying individuals are naturally going to generate new costs, but it does not mean they are intentionally abusing the SEP system,” Christopher Hansen, president of the American Cancer Society Cancer Action Network writes in that group’s letter.

Some organizations have written to express concerns about the mechanics of administering SEP rule changes.

Allison O’Toole, the chief executive officer of the St. Paul, Minnesota-based MNsure ACA exchange, has written to ask CMS for flexibility in administering any new document verification requirements.

At this point, O’Toole writes, “MNsure has no system support for processing SEPs. The entire process is manual.”

But Wesley Sanders, a Georgia insurance company worker who wrote a comment presenting his own personal views, writes that he has seen “numerous cases of SEPs that were improperly used to obtain coverage when a person became ill but not actually have a qualifying life event, and these scenarios have led to extremely high claims costs. These outlier cases distort the risk pool and make it difficult for issuers to price accurately.”

An anonymous Texas insurance agent says, “The ACA program is wrought with fraud and waste.”

“Requiring SEP verification will address only a small percentage of the reparation,” the agent writes. “Most fraud occurs at sale during [the open enrollment period], and, since many sales occur through non-licensed bodies, it would be difficult to resolve.”

An anonymous Kentucky agent says the ACA cost-sharing subsidy program, which helps the lowest-income ACA public exchange premium tax credit subsidy users pay their deductibles and co-payments, is “a big incentive for some taxpayers to purposely lower down taxable income when they foresee a large amount of medical services.

“I encountered multiple consumers like this,” the agent writes. “As more and more consumers are getting familiar with the ACA, laws, there is more chance consumers will game the system. People may just give up some income to take advantage of the very low cost-sharing in silver plans.”

Margaret Murray, chief executive officer of the Association for Community Affiliated Plans, a group for nonprofit safety-net plans, said most of the enrollment fraud ACAP members actually comes in the form of fraudulent verification documents submitted during the open enrollment period, not SEP fraud.

Many commenters asked CMS to allow for some flexibility in any SEP verification system.

Janet Stokes Trautwein, chief executive officer of the National Association of Health Underwriters, asked CMS to provide special-circumstances reviews for consumers who are unable to provide the required documents due to extraordinary circumstances beyond their control.

Related:

5 agent jabs at a draft ACA date change

Trump advisor hears Blues’ ACA market stability proposal

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