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Health Care Blog

Excluded Party Cases Dominate OIG Published Self Disclosure Settlements

Authored by John H. Fisher, II
Posted on March 21, 2017
Filed under Health Care

In 2013, the HHS Office of Inspector General issued revised protocols outlining the process through which health care providers are able to self-disclose and resolve potential liability under the OIG’s civil monetary penalty (CMP) authorities.  The 2013 Self Disclosure Protocols (SDP) clarified the process of self-disclosure and provided answers to some of the questions previously impeding provider use of the self-disclosure process.  One area the SDP clarified involved the calculation of damages where a provider discovers an employee has been excluded from the Medicare and Medicaid programs.  When a provider is a “direct billing” provider, such as a physician, it is relatively easy to identify the billings attached to that provider.  Prior to 2013, the process for estimating damages was unknown for employees who do not directly bill federal programs for their services. 

The 2013 SDP contained a suggested process for estimating damages when non-billed employees are excluded from the program.  The process is based on the cost of employing the excluded individual.  This made it much easier for providers to use the SDP in these circumstances.  Review of the recently settled self-disclosure cases confirms the process is working to encourage providers to use the SDP in cases involving exclusions.  The SDP uses a multiple of 1.5 times estimated program damages as a minimum baseline for settling SDP cases.  Calculation of damages resulting from exclusion involve identification of billing for services of a physician or other provider who receives reimbursement for their services.  Other employees such as nurses, medical assistants, administrative staff, and others use the estimated cost of employment method.

By my count there appears to have been a total of forty-nine excluded party SDP settlements from the beginning of 2016 through the publication date of this article.  This is reflective of the clarified procedure in the 2013 SDP.  Settlement amounts range from around $10,000 to a high of around $800,000.  The higher dollar amount settlements likely relate to multiple excluded parties, long-term employees, or large dollar “direct-bill” employees.

Listed settlements in cases where the disclosing party was alleged to have employed an individual it knew or should have known was excluded from participation in Federal health care programs include:

  • Precision Toxicology, LLC (Precision), California, agreed to pay $30,137.69
  • Claxton-Hepburn Medical Center (CHMC), New York, agreed to pay $23,483.39
  • Delaware Valley Community Health, Inc. (DVCH) and Fairmount Primary Care Center (FPCC), Pennsylvania, agreed to pay $27,061.58
  • Scott & White Memorial Hospital (S&W), Texas, agreed to pay $19,146.08
  • Consulate Health Care (Consulate), Florida, agreed to pay $359,388.10
  • Consulate Health Care and Perry Village Facility Operations, LLC d/b/a The Manor at Perry Village (collectively, Perry Village), Florida, agreed to pay $29,324.36
  • Good Samaritan Society HCBS-Choice, LLC d/b/a Choice Home Health Care (CHHC), Texas, agreed to pay $10,000
  • Diversicare Healthcare Services, Inc. (Diversicare), headquartered in Delaware, agreed to pay $514,424
  • Marias Care Center (Marias), Montana, agreed to pay $85,952.72
  • 125 Alma Boulevard Operations LLC d/b/a Island Health and Rehabilitation Center (IHRC), Florida, agreed to pay $30,924.11
  • AHS Oklahoma Physician Group, LLC d/b/a Utica Park Clinic (UPC), Oklahoma, agreed to pay $13,467.01
  • Where The Heart Is (WTHI), Tennessee, agreed to pay $100,000
  • Health Recovery Services, Inc. (HRS), Ohio, agreed to pay $213,564.54
  • UHS of Westwood Pembroke, Inc. d/b/a Pembroke Hospital (Pembroke Hospital), Massachusetts, agreed to pay $807,856.65
  • Fort Duncan Medical Center, L.P. d/b/a Fort Duncan Regional Medical Center (FDRMC), Texas, agreed to pay $545,995.62
  • BHC Streamwood Hospital, Inc. d/b/a Streamwood Behavioral Health System (SBHS), Illinois, agreed to pay $285,683
  • UHS of Dover, LLC d/b/a Dover Behavioral Health System (DBHS), Delaware, agreed to pay $197,320.85
  • UHS of Texoma, Inc. d/b/a Texoma Medical Center (TMC), Texas, agreed to pay $127,001.69
  • TBD Acquisition, LLC d/b/a Brook Hospital-Dupont (BHD), Kentucky, agreed to pay $119,033.54
  • La Amistad Residential Treatment Center, LLC d/b/a Central Florida Behavioral Hospital (CFBH), Florida, agreed to pay $26,744.55
  • UHS of Parkwood, Inc. d/b/a Parkwood Behavioral Health System (PBHS), Mississippi, agreed to pay $13,092.48
  • UHS of Fairmount, Inc. d/b/a Fairmount Behavioral Health System (Fairmount), Pennsylvania, agreed to pay $58,339.74
  • Community Care Physicians, P.C. (CCP), New York, agreed to pay $60,972.04
  • Moses H. Cone Memorial Hospital Operating Corporation d/b/a Cone Health System (CHS), North Carolina, agreed to pay $475,220.66
  • Natera, Inc. (Natera), California, agreed to pay $10,000
  • Palisades Health Care Partners, Inc. d/b/a ASAP Services Corporation (ASAP Services), District of Columbia, agreed to pay $66,647.28
  • Gateway Healthcare, Inc. (Gateway), Rhode Island, agreed to pay $400,000
  • Carolina Kidney Associates, P.A. (CKA), North Carolina, agreed to pay $11,805.48
  • Buckner Elam Medical (BEM) and Setal Rana, M.D. (Dr. Rana), Texas, agreed to pay $435,481.50
  • O'Connor Hospital, California, agreed to pay $207,698
  • Fort Worth Manor Nursing Center (Fort Worth Manor), Texas, agreed to pay $113,820.91
  • UMass Memorial Health Care, Inc.; UMass Memorial Medical Center, Inc.; and the Clinton Hospital Association (collectively, "UMass"), Massachusetts, agreed to pay $30,299.27
  • Beth Israel Deaconess Hospital-Needham and Medical Care of Boston Management, Inc. d/b/a Affiliated Physicians Group, Massachusetts, agreed to pay $154,506.84
  • Compliance Advantage, LLC (CAL), Kentucky, agreed to pay $32,249.15
  • Richland Memorial Hospital, Inc. (Richland), Illinois, agreed to pay $29,932.86
  • Buffalo Heart Group (BHG), New York, agreed to pay $13,084.73
  • Consulate Health Care and Vero Beach Facility Operations, LLC d/b/a Consulate Health Care of Vero Beach (collectively, "Consulate Vero Beach"), Florida, agreed to pay $30,978.42
  • Drug Abuse Comprehensive Coordinating Office, Inc. (DACCO), Florida, agreed to pay $32,189.76
  • Antelope Valley Hospital (AVH), California, agreed to pay $190,087.90
  • Alternative Consulting Enterprises, Inc. (ACE), Pennsylvania, agreed to pay $126,102.38
  • New LifeCare Hospitals of Northern Nevada, LLC d/b/a Tahoe Pacific Hospitals (New Life Care), Nevada, agreed to pay $57,425
  • KaleidAScope, Inc. (KaleidAScope), Pennsylvania, agreed to pay $18,468.30
  • Wexner Heritage Village (Wexner), Ohio, agreed to pay $10,000
  • Athena Orchard View LLC d/b/a Orchard View Manor (Orchard View), Rhode Island, agreed to pay $61,576.22
  • Metro Health Corporation and its subsidiary, Metropolitan Hospital d/b/a Metro Health Hospital (Metro Health), Michigan, agreed to pay $2,305,743.39
  • OhioHealth Corporation (OhioHealth), Ohio, agreed to pay $231,277.60
  • Health Sciences, Inc. (Health Sciences), Alabama, agreed to pay $10,000
  • Ridgeview Institute, Inc. (Ridgeview), Georgia, agreed to pay $29,113.82
  • Ocean Dental of Arkansas, PC (ODA), Arkansas, agreed to pay $17,346