Attorney - Hospice Fraud - A enumerate For Employees, Whistleblowers, Attorneys, Lawyers and Law FirmsHello everybody. Yesterday, I discovered Attorney - Hospice Fraud - A enumerate For Employees, Whistleblowers, Attorneys, Lawyers and Law Firms. Which is very helpful if you ask me so you. |
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Hospice fraud in South Carolina and the United States is an expanding qoute as the estimate of hospice patients has exploded over the past few years. From 2004 to 2008, the estimate of patients receiving hospice care in the United States grew approximately 40% to nearly 1.5 million, and of the 2.5 million citizen who died in 2008, nearly one million were hospice patients. The phenomenal majority of citizen receiving hospice care receive federal benefits from the federal government straight through the Medicare or Medicaid programs. The health care providers who provide hospice services traditionally enroll in the Medicare and Medicaid programs in order to qualify to receive payments under these government programs for services rendered to Medicare and Medicaid eligible patients. What I said. It isn't in conclusion that the actual about Attorney. You see this article for information about a person wish to know is Attorney.AttorneyWhile most hospice health care organizations provide accepted and ethical rehabilitation for their hospice patients, because hospice eligibility under Medicare and Medicaid involves clinical judgments which may follow in the payments of large sums of money from the federal government, there are titanic opportunities for fraudulent practices and false billing claims by unscrupulous hospice care providers. As up-to-date federal hospice fraud enforcement actions have demonstrated, the estimate of health care associates and individuals who are willing to try to defraud the Medicare and Medicaid hospice benefits programs is on the rise. A up-to-date example of hospice fraud tantalizing a South Carolina hospice is Southern Care, Inc., a hospice firm that in 2009 paid .7 million to resolve an Fca case. The defendant operated hospices in 14 other states, too, including Alabama, Georgia, Indiana, Iowa, Kansas, Louisiana, Michigan, Mississippi, Missouri, Ohio, Pennsylvania, Texas, Virginia and Wisconsin. The alleged frauds were that patients were not eligible for hospice, to wit, were not terminally ill, lack of documentation of concluding illnesses, and that the firm marketed to possible patients with the promise of free medications, supplies, and the provision of home health aides. Southern Care also entered into a 5-year Corporate Integrity trade with the Oig as part of the settlement. The qui tam relators received approximately million. Understanding the Consequences of Hospice Fraud and Whistleblower Actions U.S. And South Carolina consumers, including hospice patients and their family members, and health care employees who are employed in the hospice industry, as well as their Sc lawyers and attorneys, should wise up themselves with the basics of the hospice care industry, hospice eligibility under the Medicare and Medicaid programs, and hospice fraud schemes that have developed across the country. Consumers need to safe themselves from unethical hospice providers, and hospice employees need to guard against knowingly or unwittingly participating in health care fraud against the federal government because they may field themselves to menagerial sanctions, including lengthy exclusions from working in an club which receives federal funds, titanic civil monetary penalties and fines, and criminal sanctions, including incarceration. When a hospice employee discovers fraudulent conduct tantalizing Medicare or Medicaid billings or claims, the employee should not share in such behavior, and it is imperative that the unlawful conduct be reported to law enforcement and/or regulatory authorities. Not only does reporting such fraudulent Medicare or Medicaid practices shield the hospice employee from exposure to the foregoing administrative, civil and criminal sanctions, but hospice fraud whistleblowers may advantage financially under the repaymen provisions of the federal False Claims Act, 31 U.S.C. §§ 3729-3732, by bringing false claims suits, also known as qui tam or whistleblower suits, against their employers on behalf of the United States. Types of Hospice Care Services Hospice care is a type of health care aid for patients who are terminally ill. Hospices also provide keep services for the families of terminally ill patients. This care includes corporal care and counseling. Hospice care is ordinarily provided by a social agency or private firm popular ,favorite by Medicare and Medicaid. Hospice care is ready for all age groups, including children, adults, and the elderly who are in the final stages of life. The purpose of hospice is to provide care for the terminally ill inpatient and his or her family and not to cure the concluding illness. If a inpatient qualifies for hospice care, the inpatient can receive medical and keep services, including nursing care, medical social services, doctor services, counseling, homemaker services, and other types of services. The hospice inpatient will have a team of doctors, nurses, home health aides, social workers, counselors and trained volunteers to help the inpatient and his or her family members cope with the symptoms and consequences of the concluding illness. While many hospice patients and their families can receive hospice care in the relieve of their home, if the hospice patient's health deteriorates, the inpatient can be transferred to a hospice facility, hospital, or nursing home to receive hospice care. Hospice Care Statistics The estimate of days that a inpatient receives hospice care is often referenced as the "length of stay" or "length of service." The length of aid is dependent on a estimate of distinct factors, including but not limited to, the type and stage of the disease, the potential of and entrance to health care providers before the hospice referral, and the timing of the hospice referral. In 2008, the mean length of stay for hospice patients was about 21 days, the mean length of stay was about 69 days, approximately 35% of hospice patients died or were discharged within 7 days of the hospice referral, and only about 12% of hospice patients survived longer than 180 days. Most hospice care patients receive hospice care in private homes (40%). Other locations where hospice services are provided are nursing homes (22%), residential facilities (6%), hospice inpatient facilities (21%), and acute care hospitals (10%). Hospice patients are generally the elderly, and hospice age group percentages are 34 years or less (1%), 35 - 64 years (16%), 65 - 74 years (16%), 75 - 84 years (29%), and over 85 years (38%). As for the concluding illness resulting in a hospice referral, cancer is the determination for approximately 40% of hospice patients, followed by debility unspecified (15%), heart disease (12%), dementia (11%), lung disease (8%), stroke (4%) and kidney disease (3%). Medicare pays the great majority of hospice care expenses (84%), followed by private insurance (8%), Medicaid (5%), charity care (1%) and self pay (1%). As of 2008, there were approximately 4,700 locations which were providing hospice care in the United States, which represented about a 50% increase over ten years. There were about 3,700 associates and organizations which were providing hospice services in the United States. About half of the hospice care providers in the United States are for-profit organizations, and about half are non-profit organizations.
In 1965, Congress established the Medicare schedule to provide health insurance for the elderly and disabled. Payments from the Medicare schedule arise from the Medicare Trust fund, which is funded by government contributions and straight through payroll deductions from American workers. The Centers for Medicare and Medicaid Services (Cms), previously known as the health Care Financing supervision (Hcfa), is the federal agency within the United States agency of health and Human Services (Hhs) that administers the Medicare schedule and works in partnership with state governments to administer Medicaid. In 2007, Cms reorganized its ten geography-based field offices to a Consortia buildings based on the agency's key lines of business: Medicare health plans, Medicare financial management, Medicare fee for aid operations, Medicaid and children's health, gawk & certification and potential improvement. The Cms consortia consist of the following: • Consortium for Medicare health Plans Operations
Each consortium is led by a Consortium Administrator (Ca) who serves as the Cms's national focal point in the field for their firm line. Each Ca is responsible for consistent implementation of Cms programs, course and advice across all ten regions for matters pertaining to their firm line. In expanding to responsibility for a firm line, each Ca also serves as the Agency's senior supervision legal for two or three Regional Offices (Ros), representing the Cms Administrator in external matters and overseeing menagerial operations. Much of the daily supervision and execution of the Medicare schedule is managed straight through private insurance associates that contract with the Government. These private insurance companies, sometimes called "Medicare Carriers" or "Fiscal Intermediaries," are charged with and responsible for accepting Medicare claims, determining coverage, and manufacture payments from the Medicare Trust Fund. These carriers, including Palmetto Government Benefits Administrators (hereinafter "Pgba"), a agency of Blue Cross and Blue Shield of South Carolina, operate pursuant to 42 U.S.C. §§ 1395h and 1395u and rely on the good faith and specific representations of health care providers when processing claims. Over the past forty years, the Medicare schedule has enabled the elderly and disabled to collect needful medical services from medical providers throughout the United States. needful to the success of the Medicare schedule is the basal idea that health care providers accurately and legitimately submit claims and bills to the Medicare Trust Fund only for those medical treatments or services that are legitimate, uncostly and medically necessary, in full compliance with all laws, regulations, rules, and conditions of participation, and, further, that medical providers not take advantage of their elderly and disabled patients. The Medicaid schedule is ready only to obvious low-income individuals and families who must meet eligibility requirements set forth by federal and state law. Each state sets its own guidelines with regard to eligibility and services. Although administered by private states, the Medicaid schedule is funded primarily by the federal government. Medicaid does not pay money to patients; rather, it sends payments directly to the patient's health care providers. Like Medicare, the Medicaid schedule depends on health care providers to accurately and legitimately submit claims and bills to schedule administrators only for those medical treatments or services that are legitimate, uncostly and medically necessary, in full compliance with all laws, regulations, rules, and conditions of participation, and, further, that medical providers not take advantage of their indigent patients. Medicare & Medicaid Hospice Laws Which affect Sc Hospices Hospice fraud occurs when hospice organizations, by and straight through their employees, agents and owners, knowingly violate the terms and conditions of the applicable Medicare and Medicaid hospice statutes, regulations, rules and conditions of participation. In order to be able to recognize hospice fraud, hospices, hospice patients, hospice employees and their attorneys and lawyers must know the Medicare laws and requirements relating to hospice care benefits. Medicare's two main sources of authorization for hospice benefits are found in the social safety Act and the U.S. Code of Federal Regulations. The statutory provisions are primarily found at 42 U.S.C. §§ 1395d, 1395e, 1395f(a)(7), 1395x(d)(d), and 1395y, and the regulatory provisions are found at 42 C.F.R. Part 418. To be eligible for Medicare benefits for hospice care, the inpatient must be eligible for Medicare Part A and be terminally ill. 42 C.F.R. § 418.20. concluding illness is established when "the private has a medical determination that his or her life expectancy is 6 months or less if the illness runs its general course." 42 C.F.R. § 418.3; 42 U.S.C. § 1395x(d)(d)(3). The patient's doctor and the medical director of the hospice must certify in writing that the inpatient is "terminally ill." 42 U.S.C. § 1395f(a)(7); 42 C.F.R. § 418.20. After a patient's introductory certification, Medicare provides for two ninety-day advantage periods followed by an unlimited estimate of sixty-day advantage periods. 42 U.S.C. § 1395d(a)(4). At the end of each ninety- or sixty-day period, the inpatient can be re-certified only if at that time he or she has less than six months to live if the illness runs its general course. 42 U.S.C. § 1395f(a)(7)(A). The written certification and re-certifications must be maintained in the patient's medical records. 42 C.F.R. § 418.23. A written plan of care must be established for each inpatient setting forth the types of hospice care services the inpatient is scheduled to receive, 42 U.S.C. § 1395f(a)(7)(B), and the hospice care has to be provided in accordance with such plan of care. 42 U.S.C. § 1395f(a)(7)(C); 42 C.F.R. § 418.56. Clinical records for each hospice inpatient must be maintained by the hospice, including plan of care, assessments, clinical notes, signed notice of election, inpatient responses to medication and therapy, doctor certifications and re-certifications, outcome data, improve directives and doctor orders. 42 C.F.R. § 418.104. The hospice must collect a written notice of selection from the inpatient to elect to receive Medicare hospice benefits. 42 C.F.R. § 418.24. Importantly, once a inpatient has elected to receive hospice care benefits, the inpatient waives Medicare benefits for medical rehabilitation for the concluding disease upon which is the admitting diagnosis. 42 C.F.R. § 418.24(d). The hospice must designate an Interdisciplinary Group (Idg) or groups composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing concluding illness and bereavement. 42 C.F.R. § 418.56. The Idg members must provide the care and services offered by the hospice, and the group, in its entirety, must supervise the care and services. A registered nurse that is a member of the Idg must be designated to provide coordination of care and to ensure continuous estimate of each patient's and family's needs and implementation of the interdisciplinary plan of care. The interdisciplinary group must include, but is not limited to, the following suited and competent professionals: (i) A doctor of rehabilitation or osteopathy (who is an employee or under contract with the hospice); (ii) A registered nurse; (iii) A social worker; and, (iv) A pastoral or other counselor. 42 C.F.R. § 418.56. The Medicare hospice regulations, at 42 C.F.R. § 418.200, summarize the requirements for hospice coverage in pertinent part as follows: To be covered, hospice services must meet the following requirements. They must be uncostly and needful for the palliation and supervision of the concluding illness as well as connected conditions. The private must elect hospice care in accordance with §418.24. A plan of care must be established and periodically reviewed by the attending physician, the medical director, and the interdisciplinary group of the hospice schedule as set forth in §418.56. That plan of care must be established before hospice care is provided. The services provided must be consistent with the plan of care. A certification that the private is terminally ill must be completed as set forth in section §418.22. The social safety Act, at 42 U.S.C. § 1395y(a), limits Medicare hospice benefits, providing in pertinent part as follows: "Notwithstanding any other provision of this title, no payment may be made under part A or part B for any expenses incurred for items or services-... (C) in the case of hospice care, which are not uncostly and needful for the palliation or supervision of concluding illness...." 42 C.F.R. § 418.50 (hospice care must be "reasonable and needful for the palliation and supervision of concluding illness"). Palliative care is defined in the regulations as "patient and family-centered care that optimizes potential of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and to facilitate inpatient autonomy, entrance to information, and choice." 42 C.F.R. § 418.3. Medicare pays hospice agencies a daily rate for each day a beneficiary is enrolled in the hospice advantage and receives hospice care. The daily payments are made regardless of the estimate of services furnished on a given day and are intended to cover costs that the hospice incurs in furnishing services identified in the patient's plan of care. There are four levels of payments which are made based on the estimate of care required to meet beneficiary and family needs. 42 C.F.R. § 418.302; Cms Hospice Fact Sheet, November 2009. These four levels, and the corresponding 2010 daily rates, are as follows: disposition home care (2.91); continuous home care (4.10); inpatient respite care (7.83); and, general inpatient care (5.74). The compound every year cap per inpatient in 2009 was ,014.50. This cap is considered by adjusting the primary hospice inpatient cap of ,500, set in 1984, by the consumer Price Index. See Cms Internet-Only by hand 100-04, lesson 11, section 80.2; 42 U.S.C. § 1395f(i); 42 C.F.R. § 418.309. The Medicare Claims Processing Manual, at lesson 11 - Processing Hospice Claims, in Section 80.2, entitled "Cap on broad Hospice Reimbursement," provides in pertinent part as follows: "Any payments in excess of the cap must be refunded by the hospice." Hospice patients are responsible for Medicare co-insurance payments for drugs and respite care, and the hospice may charge the inpatient for these co-insurance payments. However, the co-insurance payments for drugs are limited to the lesser of or 5% of the cost of the drugs to the hospice, and the co-insurance payments for respite care are generally 5% of the payment made by Medicare for such services. 42 C.F.R. § 418.400. The Medicare and Medicaid programs wish institutional health care providers, including hospice organizations, to file an enrollment application in order to qualify to receive the programs' benefits. As part of these enrollment applications, the hospice providers certify that they will comply with Medicare and Medicaid laws, regulations, and schedule instructions, and supplementary certify that they understand that payment of a claim by Medicare and Medicaid is conditioned upon the claim and basal transaction complying with such schedule laws and requirements. The Medicare Enrollment Application which hospice providers must execute, Form Cms-855A, states in part as follows: "I agree to abide by the Medicare laws, regulations and schedule instructions that apply to this provider. The Medicare laws, regulations, and schedule instructions are ready straight through the Medicare contractor. I understand that payment of a claim by Medicare is conditioned upon the claim and the basal transaction complying with such laws, regulations, and schedule instructions (including, but not limited to, the Federal Aks and Stark laws), and on the provider's compliance with all applicable conditions of participation in Medicare." Hospices are generally required to bill Medicare on a monthly basis. See the Medicare Claims Processing Manual, at lesson 11 - Processing Hospice Claims, in Section 90 - Frequency of Billing. Hospices generally file their hospice Medicare claims with their Fiscal Intermediary or Medicare Carrier pursuant to the Cms Claims by hand Form Cms 1450 (sometime also called a Form Ub-04 or Form Ub-92), either in paper or electronic form. These claim forms consist of representations and certifications which state in pertinent part that: (1) misrepresentations or falsifications of needful facts may serve as the basis for civil monetary penalties and criminal convictions; (2) submission of the claim constitutes certification that the billing facts is true, definite and complete; (3) the submitter did not knowingly or recklessly disregard or misrepresent or conceal material facts; (4) all required doctor certifications and re-certifications are on file; (5) all required inpatient signatures are on file; and, (6) for Medicaid purposes, the submitter understands that because payment and satisfaction of this claim will be from Federal and State funds, any false statements, documents, or concealment of a material fact are field to prosecution under applicable Federal or State Laws. Hospices must also file with Cms an every year cost and data record of Medicare payments received. 42 U.S.C. § 1395f(i)(3); 42 U.S.C. § 1395x(d)(d)(4). The every year hospice cost and data reports, Form Cms 1984-99, consist of representations and certifications which state in pertinent part that: (1) misrepresentations or falsifications of facts contained in the cost record may be punishable by criminal, civil and menagerial actions, including fines and/or imprisonment; (2) if any services identified in the record were the goods of a direct or indirect kickback or were otherwise illegal, then criminal, civil and menagerial actions may result, including fines and/or imprisonment; (3) the record is a true, definite and complete statement ready from the books and records of the provider in accordance with applicable instructions, except as noted; and, (4) the signing officer is customary with the laws and regulations with regard to the provision of health care services and that the services identified in this cost record were provided in compliance with such laws and regulations. Hospice Anti-Fraud enforcement Statutes There are a estimate of federal criminal, civil and menagerial enforcement provisions set forth in the Medicare statutes which are aimed at preventing fraudulent conduct, including hospice fraud, and which help allege schedule integrity and compliance. Some of the more foremost enforcement provisions of the Medicare statutes consist of the following: 42 U.S.C. § 1320a-7b (Criminal fraud and anti-kickback penalties); 42 U.S.C. § 1320a-7a and 42 U.S.C. § 1320a-8 (Civil monetary penalties for fraud); 42 U.S.C. § 1320a-7 (Administrative exclusions from participation in Medicare/Medicaid programs for fraud); 42 U.S.C. § 1320a-4 (Administrative subpoena power for the Comptroller General). Other criminal enforcement provisions which are used to combat Medicare and Medicaid fraud, including hospice fraud, consist of the following: 18 U.S.C. § 1347 (General health care fraud criminal statute); 21 U.S.C. §§ 353, 333 (Prescription Drug Marketing Act); 18 U.S.C. § 669 (Theft or Embezzlement in connection with health Care); 18 U.S.C. § 1035 (False statements relating to health Care); 18 U.S.C. § 2 (Aiding and Abetting); 18 U.S.C. § 3 (Accessory after the Fact); 18 U.S.C. § 4 (Misprision of a Felony); 18 U.S.C. § 286 (Conspiracy to defraud the Government with respect to Claims); 18 U.S.C. § 287 (False, Fictitious or Fraudulent Claims); 18 U.S.C. § 371 (Criminal Conspiracy); 18 U.S.C. § 1001 (False Statements); 18 U.S.C. § 1341 (Mail Fraud); 18 U.S.C. § 1343 (Wire Fraud); 18 U.S.C. § 1956 (Money Laundering); 18 U.S.C. § 1957 (Money Laundering); and, 18 U.S.C. § 1964 (Racketeer Influenced and Corrupt Organizations ("Rico")). The False Claims Act (Fca) Hospice fraud whistleblowers may advantage financially under the repaymen provisions of the federal False Claims Act, 31 U.S.C. §§ 3729-3732, by bringing false claims suits, also known as qui tam or whistleblower suits, against their employers on behalf of the United States. The plaintiff in a hospice fraud whistleblower suit is also known as a relator. The most base Fca provisions upon which hospice fraud qui tam or whistleblower relators rely are found in 31 U.S.C. § 3729: (A) knowingly presents, or causes to be presented, a false or fraudulent claim for payment or approval; (B) knowingly makes, uses, or causes to be made or used, a false record or statement material to a false or fraudulent claim; (C) conspires to commit a violation of subparagraph (A), (B), (D), (E), (F), or (G);..., and, (G) knowingly makes, uses, or causes to be made or used, a false record or statement material to an enforcement to pay or transmit money or property to the Government, or knowingly conceals or knowingly and improperly avoids or decreases an enforcement to pay or transmit money or property to the Government.... There is no requirement to prove definite intent to defraud. Rather, it is only needful to prove actual knowledge of the false claims, false statements, or false records, or the defendant's deliberate indifference or reckless disregard of the truth or falsity of the information. 31 U.S.C. § 3729(b). The Fca anti-retaliation provision protects the hospice whistleblower from retaliation from the hospice when the employee (or a contractor) "is discharged, demoted, suspended, threatened, harassed, or in any other manner discriminated against in the terms and conditions of employment" for taking performance to try to stop the fraudulent activity. 31 U.S.C. § 3730(h). A hospice employee's relief includes reinstatement, 2 times the estimate of back pay, interest on the back pay, and payment for any extra damages sustained as a follow of the discrimination or retaliation, including litigation costs and uncostly attorneys' fees. A Sc hospice fraud Fca whistleblower would initially file a disclosure statement, complaint and supporting documents with the U.S. Attorney's Office in Columbia, South Carolina, and the Us Attorney General. After the disclosures are filed, a federal court complaint can be filed. The Sc agency where the frauds occurred, the relator's residence, and the defendant residence, will resolve which agency the case will be assigned. There are eleven federal court divisions in South Carolina. Once the case has been filed, the government has 60 days to resolve either or not to intervene. While this time, federal government investigators located in South Carolina will research the claims. If the case complex Medicaid, Sc Medicaid fraud unit investigators will likely come to be complex as well. If the government intervenes in the case, the U.S. Attorney for South Carolina is ordinarily the lead attorney. If the government does not intervene, the relator's Sc attorney will prosecute the case. In South Carolina, expect a qui tam case to take one to two years to get to trial. Tips on Recognizing Hospice Fraud Schemes The Hhs Office of Inspector general (Oig) has issued extra Fraud Alerts for fraudulent and abusive practices of hospices. U.S. And South Carolina hospices, patients, hospice employees and whistleblowers, their attorneys and lawyers, should be customary with these hospice fraud practices. Tips on recognizing hospice frauds in South Carolina and the U.S. Are: • A hospice contribution free goods or goods at below market value to induce a nursing home to refer patients to the hospice.
Recent Hospice Fraud enforcement Cases The Doj and U.S. Attorney's Offices have been active in enforcing hospice fraud cases. In 2009, Kaiser Foundation Hospitals located an Fca lawsuit by paying .8 million to the federal government. The defendant allegedly failed to collect written certifications of concluding illness for a estimate of its patients. In 2006, Odyssey Healthcare, a national hospice provider, paid .9 million to resolve a qui tam suit for false claims under the Fca. The hospice fraud allegations were generally that Odyssey billed Medicare for providing hospice care to patients when they were not terminally ill and ineligible for Medicare hospice benefits. A Corporate Integrity trade was also a part of the settlement. The hospice fraud qui tam relator received .3 million for blowing the whistle on the defendant. In 2005, Faith Hospice, Inc., located claims an Fca claim for 0,000. The hospice fraud allegations were generally that Faith Hospice billed Medicare for providing hospice care to patients more than half of whom were not terminally ill. In 2005, Home Hospice of North Texas located an Fca claim for 0,000 with regard to allegations of fraudulently billing Medicare for ineligible hospice patients. In 2000, Michigan osteopath Donald Dreyfuss, who pleaded guilty to criminal fraud charges, including violation of the Aks for receiving illegal kickbacks from a hospice for recommending the hospice to the staff of his nursing home, located an Fca suit for million. Conclusion Hospice fraud is a growing qoute in South Carolina and throughout the United States. South Carolina hospice patients, hospice employees, and their Sc lawyers and attorneys, should be customary with the basics of the hospice care industry, hospice eligibility under the Medicare and Medicaid programs, and typical hospice fraud schemes. Hospice organizations should take steps to ensure full compliance with Medicare/Medicaid hospice billing requirements to avoid hospice fraud allegations and Fca litigation. © 2010 Joseph P. Griffith, Jr. I hope you obtain new knowledge about Attorney. Where you may offer easy use in your everyday life. And most significantly, your reaction is passed about Attorney. Read more.. Hospice Fraud - A enumerate For Employees, Whistleblowers, Attorneys, Lawyers and Law Firms. |
Hospice Fraud - A enumerate For Employees, Whistleblowers, Attorneys, Lawyers and Law Firms
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