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Rounding Up

Senior Director of Strategic Alliances
LexisNexis Risk Solutions - Government

What is a CPT code you ask? The Current Procedural Terminology (CPT), provided by the American Medica Association, offers doctors and health care professionals a uniform language for coding medical services and procedures to streamline reporting, increasing accuracy and efficiency. And providing an opportunity to fraud. Cause if a fraudster has the rules, it knows where to break them! Shiva Akula, the owner and operator of Canon Healthcare, knew how to break the rules by manipulating the codes to overbill Medicare. To the tune of $15 million over what he provided to hospice patients.

When a provider applies that billing code, physicians are required to identify that they were physically present and performed the initial hospital care service. The physician also must personally document the admission and discharge notes and include the number of hours the beneficiary remained in inpatient hospital status. Adkula provided the documentation but ever number he provided was rounded up!  

From January 2013 to December 2019, Akula fraudulently billed for physician services, fraudulent history, and physical forms, and for home visits that were never received. Many of the patients were not even hospice eligible! Patient data was manipulated to make it billable in a hospice setting. Akula billed Medicare despite such services being medically unnecessary, and despite their inclusion in the daily hospice benefit Akula already received for its patients. And forms submitted to Medicare were hand-copied by members of his family for the work of physicians not employed by Canon Healthcare. Rounding up the physician heading count.

In the end, Akula’s care was only for himself, and not the patients. Adkula submitted invoices totaling $62 million to Medicare and received $47 million in payments for services that were partially or never provided. Akula was found guilty on November 9, 2023.

Excellent job by the Department of HHS in preventing Akula from further abusing the system.

Today’s Fraud of The Day is based on article “Former New Orleans area hospice operator found guilty in health care fraud scheme” published by The Times Picayune on November 9, 2023

A federal jury on Monday convicted a former New Orleans area hospice director of health care fraud, agreeing that he schemed over six years to overbill the government while collecting $47 million in reimbursements from Medicare, according to U.S. Attorney Duane Evans’ office.

Dr. Shiva Akula, 67, operated Canon Healthcare LLC, with offices in Louisiana and Mississippi. Federal prosecutors claimed he submitted invoices totaling $62 million to Medicare between January 2013 and December 2019. The jury convicted Akula on all 23 counts he faced after a five-day trial before U.S. District Judge Lance Africk.

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