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Top Ten Healthcare Recoveries of 2018

Posted  01/15/19
Consistent with the trend in prior years, the bulk of the Justice Department’s fraud and false claims recoveries in 2018 stemmed from healthcare fraud matters. And again, most of the funds recovered arose from cases originated by whistleblowers under the qui tam provisions of the False Claims Act. Here are the top ten healthcare recoveries of 2018 by the numbers:
    1. Amerisource Bergen Corporation - In...

Catch of the Week — PA Hospital and Health System Pays $12.5 Million to Settle FCA Allegations

Posted  12/14/18
Doctor discussing knee injury with patient seated on exam table
Coordinated Health Holding Company, LLC, a for-profit hospital and health system, and its founder, owner, and CEO, Emil DiIorio, M.D., have agreed to pay a combined $12.5 million to settle allegations of violating the False Claims Act for submitting false claims to Medicare and other federal health care programs for orthopedic surgeries. Coordinated Health is a for-profit hospital and health system based in the Lehigh...

“Widespread and Persistent” Problems in Medicare Managed Care Burden Patients and Are Potential Violations of the False Claims Act

Posted  10/30/18
The federal government’s internal watchdog for the Medicare and Medicaid healthcare programs, the U.S. Department of Health and Human Services Office of the Inspector General (OIG), has issued a report finding that Medicare Advantage Organizations (MAOs) have engaged in a “widespread and persistent” practice of inappropriately denying coverage for medical services to Medicare patientsIn addition, OIG has...

Overpayment Rule Decision Doesn't Imperil Risk Adjustment Cases: Mary Inman and Max Voldman in RAC Monitor

Posted  10/19/18
Dollars for Medicare
On September 7, a federal district court in Washington, D.C. vacated a single Centers for Medicare & Medicaid Services regulation – the 2014 “overpayment rule.”  As Constantine Cannon whistleblower attorneys Mary Inman and Max Voldman write in RAC Monitor, many Medicare Advantage Organizations have since made bold statements about the significance of this decision and its impact on the series of False Claims...

Third Circuit Clarifies the Public Disclosure Bar in United States ex rel. Silver v. PharMerica

Posted  09/7/18
Whistleblower Marc Silver secured a victory from the Third Circuit on September 4, 2018, which held that his action was not blocked by the “public disclosure bar” of the False Claims Act, reversing a lower court that had dismissed his action. The Third Circuit’s opinion appropriately recognizes that a whistleblower can use non-public information as a bridge between public information and allegations of...

AstraZeneca Settles Seroquel False Claims Action -- Again

Posted  08/9/18
On August 8, 2018, AstraZeneca agreed to pay $110 million to the state of Texas to settle allegations that it promoted two of its drugs without FDA approval resulting in health risks to children, adolescents, and other state hospital patients. This case was brought by two whistleblowers under the qui tam provisions of Texas’s Medicaid Fraud Prevention Act. The whistleblowers, two former AstraZeneca employees, among...

10th Circuit Finds that Doctor’s Judgment is Not Automatically Reasonable and Necessary

Posted  07/20/18
By Poppy Alexander Top-level heart surgeons work in a rarified world, where few may question their medical judgment. Yet that judgment is not infallible-and its presence is not in itself a protection against False Claims Act liability. The Tenth Circuit recently held as much in United States ex rel. Polukoff v. St. Mark’s Hospital et al., finding that a doctor may be exercising medical judgment while still...

Catch of the Week -- Health Quest Systems and Putnam Hospital Center

Posted  07/13/18
This week, DOJ announced a $14.7 million settlement with NY-based Health Quest Systems, Inc. (Health Quest), and its subsidiary hospital Putnam Health Center (Putnam) based on their submission of inflated and otherwise impermissible claims for payment to Medicare and Medicaid, making Health Quest and Putnam our Catch of the Week. The settlement resolves allegations stemming from three separate lawsuits bought by...

Question of the Week -- Will New CMS Initiatives Help Curb Fraud and Waste in Medicaid?

Posted  06/27/18
On June 26, 2018 CMS Administrator Seema Verma announced new initiatives to reduce fraud in the Medicaid program. The three new initiatives are to (1) emphasize program integrity in audits of state claims for federal match funds and medical loss ratios (MLRs); (2) conduct new audits of state beneficiary eligibility determinations; and (3) optimize state-provided claims and provider data. These initiatives are meant to...

Catch of the Week -- Signature HealthCARE

Posted  06/15/18
In a major victory for patients and taxpayers alike, DOJ announced an over $30 million settlement with Signature HealthCARE, LLC, a Kentucky-based company accused of overbilling federal healthcare programs for rehabilitation and skilled-nursing services. As a prime example of how valuing profits over patients can lead to fraudulent behavior, Signature HealthCARE wins the title of Catch of the Week. The settlement...
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