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June 29, 2023

Three healthcare providers—Community Health Centers of the Central Coast, Cottage Health System, and Sansum Clinic—and a California public health agency, CenCal Health, have agreed to pay a total of $68 million to settle allegations of submitting false claims to the state’s Medicaid program, in violation of state and federal False Claims Acts.  The defendants allegedly took advantage of a federal expansion of Medi-Cal coverage for previously uninsured adults by submitting duplicative or unallowed claims.  CA AG; DOJ

Tagged in: FCA Federal, FCA State, Healthcare Fraud, Medical Billing Fraud, Provider Fraud,

June 8, 2023

Billy Joe Taylor of Lavaca, Arkansas, will spend 15 years in prison and will pay nearly $30 million in restitution for submitting false and fraudulent claims to Medicare. During the COVID-19 pandemic, Taylor and his co-conspirators misused medical information and private personal information for Medicare beneficiaries, and then used that information to repeatedly submit fraudulent claims for medically unnecessary diagnostic laboratory testing. USAO WDAR

Tagged in: FCA Federal, Healthcare Fraud, Laboratory and IDTF, Lack of Medical Necessity, Medicare,

June 8, 2023

Steven King, chief compliance officer of A1C Holdings LLC, a pharmacy holding company, was convicted for violating Medicare and pharmacy benefit manager rules by securing prescriptions and refills for medically unnecessary lidocaine and diabetic testing supplies. King and his co-conspirators fraudulently billed Medicare over $50 million, taking steps to conceal their scheme by enrolling their mail order pharmacies as brick-and-mortar retail locations, shipping prescription refills for high-reimbursing medications and supplies without patient consent, concealing the ownership of A1C Holdings LLC and its pharmacies, and transferring patients among pharmacies without patient consent. King faces a maximum penalty of 20 years in prison for committing health care fraud and wire fraud. DOJ

Tagged in: Healthcare Fraud, Improper Medical Facility, Lack of Medical Necessity, Medicare, Pharma Fraud,

May 25, 2023

Vascular surgeon Vasso Godiali of Michigan has been ordered to pay $19.5 million in restitution and serve over 6 years in prison to resolve criminal allegations of defrauding Medicare, Medicaid, and Blue Cross/Blue Shield of Michigan. Godiali also agreed to pay up to $43.4 million to resolve civil allegations of violating the False Claims Act.  Although Godiali allegedly began submitting false claims in 2009, his misconduct did not come to light until a 2015 qui tam suit by Innovative Solutions Consulting LLC, which alleged Godiali billed government programs for arterial thrombectomies and stent placements that were not medically necessary and not actually performed.  Additionally, Godiali allegedly falsified medical records to justify the procedures, and improperly used a modifier code to increase his reimbursements. DOJ

Tagged in: Criminal Proceedings, FCA Federal, Healthcare Fraud, Medicaid, Medical Billing Fraud, Medicare, Provider Fraud, Whistleblower Case, Whistleblower Rewards,

April 28, 2023

Joyce Agu, of Sugar Land, TX, will spend 60 months in prison and will pay over $3 million in restitution for conspiring to pay and receive kickbacks for services billed to Medicare. Agu paid others to certify that her clients were eligible for home health services, which they were not, but she used the certifications anyway as a basis to submit false claims to Medicare. TX AG

Tagged in: Anti-Kickback and Stark, FCA Federal, Healthcare Fraud, Medical Billing Fraud, Medicare, Provider Fraud,

April 25, 2023

Attorneys George Constantine and Marc Elefant, and orthopedic surgeon Andrew Dowd, were sentenced to prison for their $31 million trip-and-fall fraud scheme. Constantine (102 months), Elefant (24 months), and Dowd (102 months) recruited participants to stage falls or falsely claim to have fallen and would then file fraudulent suits against the businesses and insurance companies where the “falls” allegedly occurred. In addition to staging the accidents and then filing suit, Constantine and Elefant would require the “victims” to receive ongoing chiropractic and medical treatment from certain designated chiropractors and doctors—including Dowd. Dowd performed nearly 300 medically unnecessary surgeries on patient-clients, at the behest of Constantine and Elefant, who then used the surgeries to boost the value of any potential settlement. In addition to prison time, they will forfeit over $8 million acquired via their fraud. DOJ

Tagged in: Chiropractic, Healthcare Fraud, Lack of Medical Necessity, Provider Fraud,

April 20, 2023

Matthew Taylor Witkowski will spend 60 months in prison for generating and purchasing fraudulent written orders for DME, and then, using his Dominican Republic-based business, marketed and sold those orders to pharmacies and DME suppliers. Witkowski’s fraud resulted in more than $8 million in false claims reimbursements being made by Medicare. Witkowski will forfeit over $4 million and pay restitution of over $8 million to Medicare. SDNY

Tagged in: Healthcare Fraud, Lack of Medical Necessity, Medical Devices and DME, Medicare, Provider Fraud,

April 20, 2023

Dr. Paul S. Koch, Koch Eye Associates, and Claris Vision violated the False Claims Act by paying kickbacks to optometrists who referred their patients to Koch and his companies for laser-assisted cataract surgery. Over a five-year period, from 2013 to 2017, Koch and his practices submitted false claims to Medicare based on those kickbacks. Koch will pay nearly $1.2 million to resolve the qui tam whistleblowers’ claims, and the two whistleblowers will receive $256,534.84 from the settlement. USAO RI

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

April 20, 2023

Miami doctors Lawrence Alexander and Dean Zusmer were sentenced to 33 months and 96 months in prison, respectively, for their scheme to defraud Medicare of $31 million. Zusmer, a chiropractor and DME company owner, paid kickbacks to acquire patient referrals and signed doctors’ orders, using overseas call centers to solicit unnecessary prescriptions from patients and telemedicine companies. Alexander, an orthopedic surgeon and co-owner of another DME company, concealed his participation by putting the DME company in the name of one of his family members. The companies received over $15 million from Medicare through their fraud. DOJ

Tagged in: Anti-Kickback and Stark, Criminal Proceedings, FCA Federal, Healthcare Fraud, Lack of Medical Necessity, Medical Devices and DME, Medicare, Provider Fraud,

April 14, 2023

Nine defendants will spend a combined 70 years in prison for their respective roles in a $126 million compounding fraud scheme. The co-conspirators defrauded the Department of Labor’s Office of Workers’ Compensation Programs and TRICARE by submitting false claims and paying kickbacks to patient recruiters and physicians for prescribing certain medications, based not on medical necessity but instead on the drugs’ hefty reimbursement rates. The patients received the compounded medications via mail, despite never requesting, wanting, or needing them. DOJ

Tagged in: Compounding Pharmacy Fraud, Criminal Proceedings, Healthcare Fraud, Lack of Medical Necessity, Medical Billing Fraud, Other Government Health Programs, Pharma Fraud, Provider Fraud,

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