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November 19, 2015

Detroit-area physician Dr. Hicham A. Elhorr was sentenced to 72 months in prison and to pay roughly $2 million in restitution for directing a multi-million dollar Medicare fraud scheme through his medical practice.  According to admissions in his plea agreement, Elhorr employed unlicensed individuals through his visiting physician practice, House Calls Physicians PLLC, who held themselves out as licensed physicians and purported to provide physician home visits and other services to Medicare beneficiaries in Michigan.  The unlicensed individuals prepared medical documentation that Elhorr and other licensed physicians signed as if they had performed the visits when, in fact, no licensed physicians had treated the beneficiaries. DOJ

Tagged in: Healthcare Fraud, Home Health and Hospice, Improper Medical Personnel, Medicare,

November 19, 2015

Florida-based hospice company Hospice of Citrus County agreed to pay roughly $3 million to settle charges the company violated the False Claims Act by knowingly billing Medicare and Medicaid for medically unnecessary and undocumented hospice services.  The allegations resolved included liability under the False Claims Act.  Specifically, the government alleged the company treated at least 52 patients with lengths of stay in excess of 1,000 days and either knowingly or recklessly failed to document a valid basis for the initial start of hospice care and/or subsequent hospice coverage.  The failure in documentation included no support for the length of hospice services; patient files that failed to document basic patient characteristics; and patient records that were either unsigned or signed with inconsistent practitioner information.  In some cases, patients were admitted to HOCC simply because their spouse was in hospice care.  DOJ (MDFL)

Tagged in: FCA Federal, Home Health and Hospice, Lack of Medical Necessity, Medicaid, Medical Billing Fraud, Medicare,

November 18, 2015

Deaconess Home Health, Inc. (formerly known as Outreach Home Health) and its owner, Lazarus Bonilla, agreed to pay $3,724,000 to resolve charges they violated the False Claims Act through the false billing of personal care worker services to the Wisconsin Medicaid Program.  Specifically, the defendants (1) intentionally recruited patients for personal care services without regards to whether the services were medically necessary; (2) instructed nurses employed by Deaconess to routinely inflate, without regard to medical necessity, the assessment of the patient that was provided to the Medicaid program; (3) failed to conduct required supervisory visits to ensure that services were in fact being provided, that services continued to be medically necessary, and that any services provided were appropriate for the needs of the patient; and (4) hired physicians to act as medical directors to sign plans of care for patients on whom they had not completed a physical examination.  The allegations first arose in three whistleblower lawsuits filed under the qui tam provisions of the False Claims Act.  Two of the whistleblowers are former employees of Deaconess.  The whistleblowers collectively will receive a whistleblower award of approximately $600,000.  (DOJ (EDWI)

Tagged in: FCA Federal, FCA State, Lack of Medical Necessity, Medicaid, Medical Billing Fraud, Whistleblower Case, Whistleblower Rewards,

November 16, 2015

HCA Holdings, Inc. (including affiliated entities Hospital Corporation of America; Parallon Business Solutions, LLC; West Florida Regional Medical Center, Inc.; HCA Health Services of Florida, Inc.; Regional Medical Center Bayonet Point; HCA Health Services of Florida, Inc.; New Port Richey Hospital, Inc.; and Medical Center of Trinity) agreed to pay $2 million to resolve charges of violating the False Claims Act through billing Medicare for unnecessary lab tests and double billing for fetal testing.  The allegations first arose in a whistleblower lawsuit by HCA employee Kelly Oxendine under the qui tam provisions of the False Claims Act.  The whistleblower will receive a whistleblower award of roughly $400,000 from the government’s recovery.  DOJ(SC)

Tagged in: Bundling and Unbundling, FCA Federal, Hospital Fraud, Laboratory and IDTF, Lack of Medical Necessity, Medical Billing Fraud, Whistleblower Case, Whistleblower Rewards,

November 13, 2015

Tamara Esponda, owner of Miami-area pharmacy Biomax Pharmacy Inc., was sentenced to 42 months in prison and to pay roughly $1.6 million in restitution for her role in the submission of more than $1.5 million in fraudulent claims to Medicare Part D.  According to admissions made in connection with Esponda’s guilty plea, Biomax Pharmacy submitted fraudulent claims to Medicare for prescription drugs that were not prescribed by physicians, not medically necessary and not provided to Medicare beneficiaries.  Esponda further admitted that in perpetrating this fraud she and her accomplices used the beneficiaries’ and doctors’ Medicare identification numbers without their consent.  DOJ

Tagged in: Lack of Medical Necessity, Medical Billing Fraud, Part D, Pharma Fraud,

November 6, 2015

Valery Bogomolny, owner of Royal Medical Supply, was convicted for his role in a $4 million Medicare fraud scheme.  According to evidence presented at trial, Bogomolny used his company to bill Medicare for power wheelchairs, back braces and knee braces that were medically unnecessary, not provided to beneficiaries or both.  The evidence further showed Bogomolny created false documentation to support his false billing claims, including creating fake reports of home assessments that never occurred.  DOJ

Tagged in: Medical Billing Fraud, Medical Devices and DME, Medicare,

November 6, 2015

Roger Rousseau, former medical director of defunct health provider Health Care Solutions Network Inc. (HCSN) was sentenced to 192 months in prison for his role in a scheme to fraudulently bill Medicare and Florida Medicaid more than $63 million.  Also sentenced to prison for their role in the scheme were therapists Liliana Marks for 72 months and Doris Crabtree and Angela Salafia, each for 60 months.  According to evidence presented at trial, HCSN purported to provide intensive mental health services to Medicare and Medicaid beneficiaries but these services were not medically necessary and were often never even provided.  HCSN also paid kickbacks to assisted living facility owners and operators who in exchange referred beneficiaries to HCSN.  In support of this scheme, Rousseau routinely signed what he knew to be fabricated and altered medical records.  And Crabtree, Salafia and Marks fabricated HCSN medical records to support the fraudulent claims.  In total, HCSN submitted roughly $63.7 million in false and fraudulent claims to Medicare.  DOJ

Tagged in: Healthcare Fraud, Medicaid, Medical Billing Fraud, Medicare, Provider Fraud,

October 30, 2015

The Department of Justice reached 70 settlements involving 457 hospitals in 43 states for more than $250 million related to cardiac devices implanted in Medicare patients in violation of Medicare coverage requirements.  The devices, called implantable cardioverter defibrillators (ICDs), are electronic devices implanted near and connected to the heart to detect and treat chaotic, extremely fast, life-threatening heart rhythms, called fibrillations, by delivering a shock to the heart, restoring the heart’s normal rhythm.  Only patients with certain clinical characteristics and risk factors qualify for an ICD covered by Medicare.  According to the government, from 2003 to 2010 each of the settling hospitals implanted ICDs during periods prohibited by the Medicare’s National Coverage Determination.  Most of the settlements originated from allegations first raised in a whistleblower lawsuit brought under the qui tam provisions of the False Claims Act by Leatrice Ford Richards, a cardiac nurse, and Thomas Schuhmann, a health care reimbursement consultant.  They have so far received a combined whistleblower award of more than $38 million from the settlements.  The Department of Justice is continuing to investigate additional hospitals and health systems.  DOJ

Tagged in: FCA Federal, Hospital Fraud, Lack of Medical Necessity, Medical Billing Fraud, Medical Devices and DME, Whistleblower Case, Whistleblower Rewards,

October 29, 2015

Warner Chilcott US Sales LLC, a subsidiary of pharmaceutical manufacturer Warner Chilcott PLC, agreed to plead guilty to a felony charge of health care fraud as part of a global settlement in which Warner Chilcott agreed to pay $125 million to resolve its criminal and civil liability arising from illegally marketing the drugs Actonel, Asacol, Atelvia, Doryx, Enablex, Estrace and Loestrin in violation of the False Claims Act and Anti-Kickback Statute.  Specifically, the government charged that between 2009 and 2013, Warner Chilcott paid physicians to induce them to prescribe Warner Chilcott drugs.  The government also alleged that Warner Chilcott employees submitted false or misleading prior authorization requests and other coverage requests to federal health care programs for the osteoporosis medications Atelvia and Actonel.  The government further claimed that Warner Chilcott employees were instructed by members of the company’s management team to make unsubstantiated superiority claims when marketing the drug Actonel.  The allegations first arose in a whistleblower lawsuit by two former Warner Chilcott sales representatives filed under the qui tam provisions of the False Claims Act.  The whistleblowers will receive a whistleblower award of approximately $22.9 million from the federal share of the civil recovery.  Whistleblower Insider

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

October 26, 2015

Valentina Kovalienko, the owner of two Brooklyn medical clinics, pleaded guilty to, and agreed to forfeit almost $30 million for, her role in a $55 million health care fraud and money laundering conspiracy.  According to her admissions, from approximately February 2008 to February 2011, Kovalienko and others executed a scheme in which patients were paid cash kickbacks to subject themselves to medically unnecessary physical and occupational therapy, diagnostic tests and office visits that were not performed by licensed professionals, and for which the clinics billed Medicare and Medicaid.  Kovalienko also admitted that to support the fraudulent claims she paid occupational and physical therapists to falsify patient charts and billing records.  DOJ

Tagged in: Anti-Kickback and Stark, Healthcare Fraud, Improper Medical Personnel, Lack of Medical Necessity, Medicaid, Medical Billing Fraud, Medicare, Provider Fraud,

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