Opinion ID: 1085312
Heading Depth: 3
Heading Rank: 4

Heading: Medicare contractors and investigators

Text: Gina Bertram is a fraud analyst for a company that works for the National Supplier Clearinghouse (the “NSC”). The NSC, a Medicare contractor, authorizes companies to bill Medicare for durable medical equipment and monitors the billing process. It issues Medicare billing numbers to DME companies, receives and processes the applications for approval to bill Medicare, and monitors the DME companies for fraud. Ms. Bertram reviewed the report from the NSC’s September 2008 inspection of First Century, notified First Century of the violations found during the inspection, and ultimately revoked First Century’s Medicare billing privileges for non-compliance. Steven Scott Ward is a lead investigator for Health Integrity, which contracts with Medicare to investigate fraud. He investigated First Century after a routine inspection of new providers revealed that it was billing for orthotics and power mobility devices at a high rate. -7- 3. Mr. Ohaka’s Other DME Providers Besides his involvement in First Century, Mr. Ohaka owned three DME companies in Oklahoma—Optimed, Vitacare, and Providence—and controlled another DME company in Texas. The Texas company, Luant, was registered under the name of an individual not involved in this case. a. Optimed Optimed’s application for enrollment in Medicare was approved in 2005, allowing it to submit claims to Medicare for reimbursement. In 2006, the government began investigating Optimed because 90 percent of its claims to Medicare were filed using a special Medicare billing code called “the CR modifier.” The CR modifier eliminated certain documentation requirements and allowed for faster processing of claims to replace equipment lost due to Hurricanes Katrina and Rita. Around October 2006, Medicare placed Optimed on “prepayment review,” which requires that a DME company provide supporting documentation for each claim that it has submitted before Medicare will approve reimbursement. Optimed was unable to submit the required documentation for prepayment review, and the NSC revoked Optimed’s identification number and its privilege to bill Medicare. b. Vitacare Vitacare was enrolled to bill for Medicare reimbursement in early 2007. Mr. Ohaka listed his wife as Vitacare’s owner on the Medicare enrollment application. When investigators from the NSC conducted a site visit to approve Vitacare’s application and -8- encountered Mr. Ohaka, he told them that he was the owner. Around mid-2007, Health Integrity began investigating Vitacare and noticed that it was billing with the CR modifier at a high rate. Vitacare was placed on prepayment review in the spring of 2008. Vitacare was unable to comply with the documentation requirements of prepayment review, and its Medicare billing privileges were revoked. c. Providence Providence was approved to bill Medicare in early 2008. Medicare began investigating it in July or August 2008 because Providence had been billing for orthotics at a high rate. Providence was placed on prepayment review. When it could not document several claims, its Medicare provider number was revoked. d. Luant In December 2008, Medicare conducted a site visit of Luant, Mr. Ohaka’s Texas DME provider. Although Helen Etinfoh was listed on the company’s Medicare application as the owner, employees told Medicare representatives that Mr. Ohaka was the owner. Medicare subsequently determined that Mr. Ohaka and Ms. Etinfoh had agreed that he would pay her in exchange for use of her name as owner on Luant’s Medicare claims. Mr. Ohaka was indicted for fraud in July 2009 based on his involvement with Luant.