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June 14, 2021

Centene Corp. will pay a total of $143.8 million to resolve claims by Ohio and Mississippi that it overbilled the states' Medicaid programs in its role as a pharmacy benefit manager.  The states alleged that Centene engaged in practices including "spread pricing," charging more than allowed price caps based on industry standards, inflation of dispensing fees, failure to disclose discounts received, and claiming reimbursement for prescriptions already paid for by third parties.  Ohio will receive $88.3 million, and Mississippi will receive $55.5 million.  OH; MS

Tagged in: Drug and DME Pricing, FCA State, Healthcare Fraud, Medicaid, Pharma Fraud,

June 11, 2021

Two integrative chiropractic practices in Pennsylvania and their chiropractor owners have agreed to pay over $800,000 to resolve liability under the False Claims Act in connection with an electro-acupuncture device.  The settling parties are Discover Optimal Healthcare, affiliate Weigner Healthcare Management Group, LLC, and owner Jason Weigner (collectively, “Weigner”), and Yucha Medical Pain Management & Chiropractic Rehabilitation, LLC, and owners Randolph Yucha and Rodney Gabel.  Between 2016 and 2017, the parties allegedly billed Medicare and the Federal Employees Health Benefit Program for the surgical implantation of neuro-stimulators, even though the devices involved—ANSiStim—are not reimbursable and can be applied with adhesives.  USAO EDPA

Tagged in: FCA Federal, Healthcare Fraud, Medical Billing Fraud, Medical Devices and DME, Medicare, Other Government Health Programs, Provider Fraud,

June 10, 2021

Three Texas-based healthcare providers who allegedly billed Medicare for non-reimbursable procedures involving electro-acupuncture devices have agreed to pay over $1 million in settle their liability under the False Claims Act.  For up to two years, each of the providers—Ledger Foot & Ankle, P.A., SPR Medical Group d/b/a Superior Physical Medicine, and Precision Spine and Pain Management—allegedly billed the application of two pain management devices, ANSiStim and STIVAX, as though they were implantable neurostimulators, when in fact their application was non-surgical and non-invasive.  Following a Medicare audit, Superior and Precision self-disclosed improperly billed claims and initiated refund payments to Medicare.  USAO WDTX

Tagged in: FCA Federal, Healthcare Fraud, Medical Billing Fraud, Medical Devices and DME, Medicare, Provider Fraud,

June 8, 2021

The chiropractor owner and operator of Texas-based Campbell Medical Group PLLC and Johnson Medical Group PLLC d/b/a Campbell Medical Clinic has agreed to pay $2.6 million to settle claims that she and the entities defrauded Medicare and TRICARE.  As part of the settlement, Suhyun An and her medical entities will be excluded from participating in federal healthcare programs for ten years.  Ms. An and the medical entities allegedly improperly obtained over $3.9 million in reimbursement for unbillable implantations of neurostimulator electrodes.  USAO SDTX

Tagged in: FCA Federal, Healthcare Fraud, Medical Billing Fraud, Medical Devices and DME, Medicare, Other Government Health Programs,

May 28, 2021

Erik Santos of Georgia was sentenced to more than 11 years in prison following his guilty plea on healthcare fraud charges.  Santos conspired with Florida compounding pharmacy Patient Care America and others to recruit Tricare beneficiaries to fill prescriptions for expensive, supposedly tailor-made, compounded medications that consisted of little more than common pain or scar creams, but came with price tags as high as $10,000-$15,000 per month.  The beneficiaries did not need the medications, which had little to no therapeutic value, and Santos secured the prescriptions by paying doctors, who had not actually seen the beneficiaries, to approve pre-printed prescriptions for large amounts of these medications.  Santos’s fraudulent referrals caused an actual loss to the Tricare program of approximately $12 million.  PCA pharmacy paid Santos over $7 million in prescription referral kickbacks.  In addition to the prison sentence, the Court imposed restitution in the amount of $11.8 million and entered a forfeiture judgement of approximately $7.6 million.  USAO SD FL

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

May 26, 2021

Nurse practitioner Trivikram Reddy was sentenced to 20 years in prison following his guilty plea on healthcare conspiracy and wire fraud charges.  Reddy stole the identities of six physicians to submit fraudulent bills to Medicare and private insurers including Blue Cross Blue Shield of Texas, Aetna, UnitedHealthcare, Humana, and Cigna. When federal agents began their investigation, Reddy took steps to manufacture medical records to support his fraudulently-submitted bills, and diverted millions of dollars in proceeds of the fraud to himself.  In addition to the prison sentence, Reddy was ordered to pay more than $52 million in restitution.  USAO ND TX

Tagged in: Criminal Proceedings, Healthcare Fraud, Medical Billing Fraud, Provider Fraud,

May 26, 2021

A licensed insurance broker, Tarek Abou-Katwa, was sentenced to 70 months in prison for his role in a scheme to defraud CareFirst BlueCross BlueShield of more than $3.8 million.  According to evidence presented at trial, Mr. Abou-Katwa created fictitious employees and altered years of birth of actual employees to lower the average age of insured groups and fraudulently obtain lower insurance premiums.  He then inflated the rates charged to clients and pocketed the difference, which was in excess of $3.6 million.  When audited, he created false sense reports and other documents.  Mr. Abou-Katwa will also pay $3.8 million in restitution and forfeit $8.4 million.  DOJ

Tagged in: Criminal Proceedings, Healthcare Fraud, Medical Billing Fraud,

May 26, 2021

HEAG Pain Management Center, P.A. (HEAG) and its owner, Dr. Kwadwo Gyarteng-Dakwa (Dr. Dakwa), have agreed to pay $500,000 to settle allegations of defrauding Medicare and Medicaid.  According to the government, the defendants knowingly submitted or caused the submission of claims for medically unnecessary diagnostic testing between 2011 and 2016.  AG NC; USAO MDNC

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

May 25, 2021

Upper Allegheny Health System (UAHS), which operates dental clinics in New York and Pennsylvania, has agreed to pay $2.7 million to resolve whistleblower-brought allegations of submitting false claims to Medicaid in violation of the federal and New York False Claims Acts.  Between 2010 and 2015, UAHS had billed Medicaid for dental services performed using improperly sterilized handpieces, which are considered semi-critical devices and need to be properly heat sterilized between patients.  AG NY; USAO WDNY; USAO WDPA

Tagged in: FCA Federal, FCA State, Healthcare Fraud, Medicaid, Medical Devices and DME, Provider Fraud, Whistleblower Case,

May 21, 2021

SavaSeniorCare LLC and related entities (“Sava”) will pay $11.2 million, plus potentially more pursuant to an “ability-to-pay” settlement, to resolve allegations that Sava violated the False Claims Act by causing its skilled nursing facilities to bill Medicare for rehabilitation therapy services that were not reasonable, necessary, or skilled, and that Sava billed the Medicare and Medicaid programs for grossly substandard (i.e., “worthless”) skilled nursing services.  The settlement stems from four separate qui tam complaints filed by whistleblowers Rita Hayward, Trammel Kukoyi, Terrence Scott, James Thornton, and Barbara Roberts, who will share an undisclosed portion of the government’s recovery.  In 2015, the United States intervened in the litigation and filed a consolidated False Claims Act complaint, alleging inter alia that Sava had exerted significant pressure on its skilled nursing facilities to meet unrealistic corporate targets for the highest Medicare reimbursement rates without regard to patients’ actual clinical needs, and improperly delayed the discharge of patients from its facilities in order to increase billings.  Sava will enter into a five-year Corporate Integrity Agreement as part of the settlement.  DOJ

Tagged in: FCA Federal, Healthcare Fraud, Improper Medical Personnel, Lack of Medical Necessity, Medicaid, Medicare, SNF, Upcoding, Whistleblower Case,

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