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March 15, 2019

Long Island chiropractor Raymond R. Pellegrino pleaded guilty to charges arising from his fraudulent billing of private insurance companies.   Pellegrino falsely billed Anthem Empire Blue Cross/Blue Shield over $2 million for services claimed to have been provided by doctors employed by him, when knew those services had not, in fact, been provided.  USAO EDNY

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

March 15, 2019

Connecticut Behavioral Health Associates, P.C. and its principal, psychiatrist Bassam Awwa, who treat patients for substance abuse, will pay $3.3 million in a settlement with the federal government and Connecticut. Defendants allegedly billed Medicare and Medicaid for multiple drug screening tests per patient visit, instead of the single test authorized.  In addition, defendants submitted bills for urine alcohol screening that were already a component of the single test, and for definitive urine drug tests that were not actually performed.  USAO CT

Tagged in: Bundling and Unbundling, FCA Federal, Healthcare Fraud, Laboratory and IDTF, Medical Billing Fraud, Provider Fraud,

March 14, 2019

The former owner and former COO of Atlanta-based Primera Medical Group, Shailesh Kothari and Timothy McMenamin, were sentenced to prison terms of 6.75 and 7.75 years, respectively, for their roles in submitting more than $8.5 million in fraudulent invoices to private insurance companies for allergy testing and allergy immunotherapy services that were never provided and were not medically necessary.  Defendants submitted bills using the NPIs of doctors who had not performed the tests and, in fact, had no knowledge of the services.  To cover up the fact that the services were not provided, defendants would create false laboratory reports for insurers and patients who requested them.  USAO ND GA

Tagged in: Criminal Proceedings, Healthcare Fraud, Medical Billing Fraud, Private Insurance Whistleblower Reward Programs, Provider Fraud,

March 13, 2019

Following an earlier guilty plea, Waveney Blackman, the owner of Washington, D.C. durable medical equipment company WaveCare Health Services, was sentenced to 3.5 years in prison for her role in submitting nearly $10 million in fraudulent claims to Medicaid for would care products that were not actually purchased and provided.  Blackman was also ordered to forfeit $9.4 million and pay restitution in the same amount.  DOJ; USAO DC

Tagged in: Criminal Proceedings, Medical Billing Fraud, Medical Devices and DME,

March 7, 2019

A Connecticut-based durable medical equipment supplier, Med Tech, and its owner, Thomas Macre, Sr., have agreed to pay more than $467,000 to resolve allegations of violating the federal and state False Claims Acts. The alleged misconduct involved billing Medicaid for unprovided and medically unnecessary back braces and electrical stimulation units. USAO CT

Tagged in: FCA Federal, FCA State, Healthcare Fraud, Lack of Medical Necessity, Medicaid,

March 6, 2019

A Texas woman has been sentenced to 30 years in prison and ordered to pay more than $15 million for her role in a $50 million scheme involving healthcare fraud and money laundering. Daniela Gozes-Wagner was accused of running 28 fake medical testing facilities from 2009, and billing Medicare and Medicaid for tests that were not performed or medically necessary. As part of the scheme, she employed personnel to answer phones and prevent inspectors from entering "testing facilities" that were virtually empty. USAO SDTX

Tagged in: Healthcare Fraud, Lack of Medical Necessity, Medicaid, Medicare, Misrepresentations,

February 27, 2019

The owner and operator of a drug marketing company has pleaded guilty for his role in a $200 million scheme to defraud TRICARE in one of the largest healthcare fraud cases said to come out of Mississippi. Between 2012 and 2016, Howard Randall Thomley of Advantage Marketing Professionals allegedly recruited TRICARE beneficiaries to accept millions of dollars of medically unnecessary compounded medications by paying them a percentage of prescription revenues. The prescriptions forms — signed by medical professionals who never saw the recruited beneficiaries — were then filled by a compounding pharmacy, Advantage Pharmacy, who paid Thomley a portion of the reimbursements. For his role in the scheme, Thomley now faces a maximum sentence of 10 years in federal prison at his sentencing in July. USAO SDMS

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

February 25, 2019

Skyline Urology will pay $1.85 million to resolve allegations under the federal False Claims Act that it improperly billed Medicare for evaluation and management (E&M) services that did not meet the criteria for separate billing.  Skyline allegedly used "Modifier 25" to unbundle its E&M billing even when the E&M services were provided on the same day as other billed medical services and were not significant, separately identifiable, and beyond those ordinarily involved with the associated procedure.  A whistleblower, James M. Cesare, filed a qui tam complaint, and will receive a relator's share of approximately $323,750.  DOJ

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

February 22, 2019

Marketers, doctors, lawyers, and medical service provider defendants were sentenced this week for their roles in a multi-million dollar California worker's compensation fraud scheme in the San Diego area.  The defendants recruited patients and referred them to co-defendant attorneys to file fraudulent claims on their behalf and medical providers who performed often unnecessary and painful medical procedures for which they would then bill insurers including California Workers' Compensation.  Ronald Grusd, a doctor who owned a diagnostic imaging company, was sentenced to 10 years in prison and ordered to forfeit $1.3 million.  Fermin Iglesias, who worked as a patient capper, was sentenced to 5 years in prison and ordered to forfeit $1 million. Julian Garcia, who provided services to assist the referrals and kickbacks, was sentenced to three years in prison.  Jennifer Louise White, who marketed to providers in the network, was sentenced to two years in prison.  Sean O'Keefe, an attorney who filed fraudulent claims on behalf of patients, was sentenced to 13 months in prison and ordered to forfeit $300,000.  Steven Rigler, a chiropractor, was sentenced to six months in prison.  USAO SD Cal.

Tagged in: Anti-Kickback and Stark, Criminal Proceedings, Healthcare Fraud, Medical Billing Fraud, Other Government Health Programs, Provider Fraud,

February 22, 2019

The owner of New York Pharmacy, Inc., NYC Pharmacy Inc., and NY Healthfirst Pharmacy Inc., pharmacist Hin T. Wong, has pleaded guilty to criminal charges arising from millions of dollars in false billing to New York's Medicaid program for HIV drugs.  Wong billed Medicaid for medications that she never dispensed, a scheme disclosed by an investigation confirming that Wong's pharmacies did not purchase a sufficient inventory of medication from licensed drug wholesalers to account for the quantity of medication for which Wong’s pharmacies billed Medicaid and Medicaid Managed Care Organizations.  In addition, Wong paid kickbacks to individuals to bill for medications that were not, in fact, dispensed.  Under a related civil settlement, Wong will surrender over $3.6 million to the state.  NY

Tagged in: Medicaid, Medical Billing Fraud, Pharma Fraud,

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