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Group Health Cooperative (now a subsidiary of Kaiser Permanente) – Medicare Advantage Fraud ($6.375 million)

Constantine Cannon represents whistleblower Teresa Ross against Group Health Cooperative, an insurance company that participates in the Medicare Advantage program. GHC has agreed to pay $6.375 million to resolve allegations that the insurance plan improperly collected money from the Medicare Advantage program by overstating how sick its beneficiaries were. Ms. Ross is a former employee of GHC, where she worked for 14 years; her most recent position was the director of risk adjustment services. In her complaint, Ms. Ross alleged that GHC had improperly relied on coders’ interpretations of diagnostic tests, prescriptions, and entries in problem lists to come up with diagnoses and that it had also submitted other codes that were false because they were diagnosed by inappropriate providers, fell outside service year, or the patient had no evidence of a current condition. See Press Release and Whistleblower Insider for more.

Visiting Nurse Service of New York – Medicare/Medicaid Home Health Care Fraud ($57 million)

Constantine Cannon represented whistleblower Edward Lacey against Visiting Nurse Service of New York – the largest not-for-profit home health care agency in the United States.  VNSNY agreed to pay $57 million to resolve allegations it failed to provide home health care visits and services to tens of thousands of New Yorkers and fraudulently billed Medicare and Medicaid.  Mr. Lacey was an executive at VNSNY for 16 years.  In his complaint, Mr. Lacey alleged that VNSNY failed to provide its patients all the critical nursing and therapy visits and services their doctors prescribed under the patient Plans of Care.  He contended that by failing to provide this care, VNSNY endangered the welfare of tens of thousands of its patients while maximizing the company's Medicare and Medicaid reimbursement.  Mr. Lacey's claims concerning alleged Plan of Care failures impact the entire home health care industry.  This is the first reported False Claims Act settlement involving allegations of a home health agency failing to follow patient Plans of Care.  It also is the largest non-kickback False Claims Act settlement ever against a home health care company and the second largest settlement of any home health care fraud case.  Read more: Press Release; Whistleblower Insider.

Sharp HealthCare — Medicare Fraud/Kickbacks (undisclosed settlement amount)

Three of our whistleblower attorneys represented a whistleblower in a qui tam action under the False Claims Act against Sharp HealthCare, a regional hospital system in San Diego.  Our client alleged that the Sharp Healthcare Center for Research, Sharp’s clinical-trial research arm, fraudulently billed government payers in violation of “secondary payer” rules that prohibit billing the government when other payers will pay for a patient’s care. Our whistleblower client also alleged that Sharp cultivated an illegal kickback scheme to entice prospective trial sponsors to host clinical trials at Sharp by regularly undervaluing Sharp’s costs involved in managing clinical trials.  By offering below-market value incentives and billing government and commercial insurers for injuries, the lawsuit alleged that Sharp sought to increase its attractiveness to trial sponsors. Sharp’s alleged purpose was to burnish the organization’s reputation and offer a lucrative stream of income for Sharp-affiliated physicians involved in clinical trials. Sharp settled the whistleblower’s case for an undisclosed amount.  Read more here.

Skyline Urology — Healthcare Fraud ($2.1M)

Constantine Cannon represented a whistleblower in a qui tam lawsuit that alleged that from 2013 through 2016 a large urology practice had fraudulently and systematically misused a billing code in order to increase reimbursements from insurers, including Medicare and private insurers in California. The code, modifier 25, is properly used when a physician performs an evaluation and management service and a separate and distinct service on the same day. Billing with modifier 25 when no distinct service occurred can improperly inflate reimbursement rates and is known as “unbundling fraud.” The Federal Government recovered $1.85M and the State of California recovered $250,000 to resolve the allegations. For his efforts in uncovering the fraud, the whistleblower received a portion of both recoveries. See The National Law Review and Becker’s ASC Review for more.

Bay Sleep Clinic – Medicare Fraud/Unapproved Facilities, Unlicensed Technicians, and Physician Kickbacks ($2.6M).

Constantine Cannon represented whistleblower Elma Dresser, a sleep technician and former Bay Sleep employee. Ms. Dresser alleged that Bay Sleep Clinic and associated businesses, a network of sleep clinics in the San Francisco Bay Area, fraudulently billed Medicare for sleep studies conducted by unlicensed technicians in unapproved locations; improperly dispensed durable medical equipment from unapproved locations using unlicensed technicians; and paid doctors for referrals in violation of the federal Anti-Kickback Statute. The government joined a portion of the case, and in 2016, defendants agreed to pay $2.6 million to settle the matter. For her significant contributions, the relator’s share award was almost 21% of the government’s recovery. See DOJ for more.

Zwanger-Pesiri Radiology – Medicare and Medicaid Fraud ($10.5M).

Two of our whistleblower attorneys led the representation of Linda Gibb and Donna Geraci, former billing specialists at Zwanger-Pesiri Radiology in Long Island, New York. Ms. Geraci and Ms. Gibb brought a qui tam action under the False Claims Act (FCA) against Zwanger-Pesiri, alleging the company defrauded the government by performing unnecessary testing, charging for services not performed, and using uncredentialed physicians. The government joined the case, and in 2016, Zwanger-Pesiri paid $8.1M to settle civil allegations in the FCA case, as well as $2.4M in related criminal forfeiture. Ms. Geraci and Ms. Gibb received a whistleblower award of $1.25M collectively. See DOJ for more.

Rose Cancer Center — Medicare Fraud ($5.7 million).

Two of our whistleblower attorneys co-led the representation of Kristi Beeson who reported Medicare fraud violations at her former employer Rose Cancer Center in Mississippi. Ms. Beeson, who was a laboratory technician for the clinic, brought a qui tam action under the False Claims Act against the clinic alleging, among other things, unqualified technicians performing bone marrow biopsies, diluting chemotherapy drugs, and doctoring patient records to conceal the clinic’s fraudulent Medicare billings. The physician who owned and ran the practice, Dr. Meera Sachdeva, plead guilty to various Medicare fraud violations, forfeited $5.7 million, and is now serving a 20 year prison sentence for her crimes. Ms. Beeson, along with three other whistleblowers, collectively received a whistleblower award of $525,000 for their efforts in exposing the fraud. See Clarion Ledger for more.

Health Line Clinical Laboratories — Medicare Fraud/Unnecessary on Nonexistent Testing ($10 million).

One of our whistleblower attorneys led the representation of two whistleblowers who brought a qui tam action under the False Claims Act alleging the medical laboratory was charging for tests not performed or not necessary. For many of the tests involved, records suggested treating physicians had ordered over inclusive “747” panels, and the defense relied heavily on these order forms. The Department of Justice was persuaded the defendants’ conduct caused the unnecessary testing and intervened. Following the defeat of motions to dismiss and focused discovery the case settled for $10 million. The whistleblowers received 18% of the government recovery.

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