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Sutter Health – Medicare Advantage Fraud ($90 million)

Constantine Cannon represented whistleblower Kathy Ormsby in a False Claims Act litigation against Sutter Health and its affiliates that resulted in a $90 million settlement – the largest Medicare Advantage FCA settlement to date against a hospital system, and the second largest reported Medicare Advantage fraud settlement to date. Ms. Ormsby, a former Risk Adjustment Factor Project Manager at Sutter Health affiliate Palo Alto Medical Foundation, alleged the Sutter Health defendants inflated the number and severity of Medicare Advantage patient diagnoses, manipulated patient records, ignored audit “red flags,” and engaged in other misconduct to increase patient risk scores and obtain Medicare Advantage payments to which they were not entitled. In Spring 2019, the Government intervened in Ms. Ormsby’s case as to PAMF, and Ms. Ormsby continued to pursue her claims against the other Sutter Health affiliates on a non-intervened basis. This settlement resolves all claims and follows Sutter’s unsuccessful effort to dismiss both the complaints. Read more: Press Release; Whistleblower Insider.

Tagged in: FCA Federal, Healthcare Fraud, Hospital Fraud, Managed Care, Provider Fraud, Risk Adjustment Fraud, Upcoding,

Mid Dakota Clinic – Medicare Fraud/ASC Kickbacks ($5.45M)

The Constantine Cannon team represented Jeffery Neuberger, the former CEO of a medical group in North Dakota, in a 2017 False Claims Act case alleging a scheme in violation of the Anti-Kickback Statute (AKS) between the medical group and its wholly owned ambulatory surgery center (ASC). The AKS is intended to prevent abuses (such as unnecessary treatments) that can occur when a doctor makes money from referring patients for goods or services. The ASC safe-harbor to the AKS is limited; it essentially permits ASC ownership only by surgeons who perform procedures or surgeries in the ASC as a functional extension of his or her office. The lawsuit alleges that all of the multi-practice physician owners profited from referrals, not only the surgeons, and that they refused to give up this lucrative income stream despite knowing that it violated the AKS. In November 2019, Mid Dakota Clinic, its affiliated building partnership, and insurer agreed to pay the United States $4.15 million to resolve the case. The clinic additionally paid $1.3 million for the whistleblower’s attorneys’ fees and costs, for a total payment of $5.45 million. The United States awarded Mr. Neuberger a 25% relator’s share of its recovery.

Tagged in: Anti-Kickback and Stark, FCA Federal, Healthcare Fraud, Medicare, Provider Fraud, Whistleblower Rewards,

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.

Tagged in: Anti-Kickback and Stark, FCA Federal, FCA State, Healthcare Fraud, Hospital Fraud, Medicaid, Medical Billing Fraud, Medical Devices and DME, Medicare, Other Government Health Programs, Pharma Fraud, Private Insurance Whistleblower Reward Programs, Provider Fraud, Whistleblower Rewards,

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.

Tagged in: Bundling and Unbundling, FCA Federal, Healthcare Fraud, Medical Billing Fraud, Private Insurance Whistleblower Reward Programs, Provider Fraud, Whistleblower Case, Whistleblower Rewards,

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.

Tagged in: Anti-Kickback and Stark, FCA Federal, Healthcare Fraud, Improper Medical Facility, Improper Medical Personnel, Laboratory and IDTF, Medicare, Provider Fraud, Whistleblower Rewards,

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.

Tagged in: FCA Federal, Healthcare Fraud, Improper Medical Personnel, Lack of Medical Necessity, Medicare, Provider Fraud, Whistleblower Rewards,

DaVita — Medicare Fraud/Kickbacks ($400 million)

Two of our whistleblower attorneys led the representation of David Barbetta, a former financial analyst for DaVita HealthCare Partners, one of the largest providers of dialysis services in the United States. Mr. Barbetta brought a qui tam action under the False Claims Act against DaVita alleging the company violated the Anti-Kickback Statute by paying physicians to refer their patients to DaVita clinics for dialysis. According to the complaint, DaVita sold doctors shares of DaVita clinics at below fair market value, and purchased doctors’ interests in other clinics at above fair market value. The government joined the case, and alleged that DaVita had entered into these sweetheart deals with doctors, which gave the doctors returns of over 100%, and the doctors then steered their patients to DaVita clinics. In 2014, DaVita paid $400 million to settle the case, the largest stand-alone kickback settlement to date. See Denver Post and Modern Healthcare for more.

Tagged in: Anti-Kickback and Stark, FCA Federal, Healthcare Fraud, Medicare, Provider Fraud, Whistleblower Rewards,

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.

Tagged in: FCA Federal, Healthcare Fraud, Improper Medical Personnel, Lack of Medical Necessity, Medicare, Provider Fraud, Whistleblower Rewards,

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