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December 23, 2015

Memorial Health, Inc., Memorial Health University Medical Center, Inc., Provident Health Services, Inc., and MPPG, Inc. (d/b/a Memorial Health University Physicians) agreed to pay roughly $10 million to settle charges they violated the False Claims Act by submitting claims to the Government in violation of the Stark Law which prohibits hospitals from entering into improper financial relationships with referring physicians.  The settlement is the largest civil health care fraud recovery in the history of the United States Attorney’s Office for the Southern District of Georgia.  The allegations first arose in a whistleblower lawsuit filed by former Memorial Health CEO Phillip Schaengold under the qui tam provisions of the False Claims Act.  The whistleblower will receive a yet-to-be-disclosed whistleblower reward from the proceeds of the government’s recovery. DOJ (SDGA)

Tagged in: Anti-Kickback and Stark, FCA Federal, Hospital Fraud, Whistleblower Case, Whistleblower Rewards,

November 24, 2015

The former CFO of Long Beach, California-based Pacific Hospital, two orthopedic surgeons and two others have been charged in long-running health care fraud schemes that illegally referred thousands of patients for spinal surgeries and generated nearly $600 million in fraudulent billings.  The wide-ranging kickback scheme, which involved dozens of surgeons, orthopedic specialists, chiropractors, marketers and other medical professionals, involved improper referrals to Pacific Hospital and Hawaiian Hospital.  The most recent targets of the government’s investigation, all of whom have agreed to plead guilty, include: former Pacific Hospital CFO James L. Canedo; orthopedic surgeons Philip Sobol and Mitchell Cohen; chiropractor Alan Ivar; and health care marketer Paul Richard Randall, previously affiliated with Pacific Hospital and Tri-City Regional Medical Center in Hawaiian Gardens.  Under the terms of their plea agreements, Sobol faces a federal prison term of up to 10 years; Canedo, Ivar and Randall face up to five years in prison; and Cohen faces up to three years in prison.  All of them will be required to pay restitution to the victims of the scheme, which in Canedo’s case will be at least $20 million.  Whistleblower Insider

Tagged in: Anti-Kickback and Stark, FCA Federal, Hospital Fraud, Lack of Medical Necessity, Provider Fraud,

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,

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 16, 2015

South Carolina-based Tuomey Healthcare System agreed to pay $72.4 million to settle charges of violating the False Claims Act by billing Medicare for services referred by physicians with whom the hospital had improper financial relationships.  Under the settlement, Tuomey also will be sold to Palmetto Health, a multi-hospital healthcare system based in Columbia, South Carolina.  According to the government, Tuomey violated the Stark law by entering into contracts with 19 specialist physicians that required them to refer their outpatient procedures to Tuomey in exchange for compensation that far exceeded fair market value and included part of the money Tuomey received from Medicare for the referred procedures.  The settlement follows a jury trial where the court entered judgement against Tuomey for more than $237 million.  The case arose from a whistleblower lawsuit filed under the qui tam provisions of the False Claims Act by Dr. Michael K. Drakeford, an orthopedic surgeon who was offered, but refused to sign, one of the illegal contracts.  Dr. Drakeford will receive a whistleblower award of roughly $18.1 million from the settlement.  Whistleblower Insider

Tagged in: Anti-Kickback and Stark, FCA Federal, Hospital Fraud, Whistleblower Case, Whistleblower Rewards,

October 14, 2015

Santiago Borges, Erik Alonso and Cristina Alonso, all of Miami, pleaded guilty to federal healthcare fraud charges.  Borges owned the now-defunct mental health centers R&S Community Mental Health Inc. and St. Theresa Community Mental Health Center Inc., and was an investor in New Day Community Mental Health Center LLC .  Erik Alonso was the clinical director of all three centers.  Cristina Alonso was a therapist at R&S.  They admitted the clinics billed Medicare for costly partial hospitalization program services that were not medically necessary or not provided to patients.  Borges also admitted he paid kickbacks to patient recruiters who, in exchange, referred beneficiaries to the centers.  DOJ

Tagged in: Healthcare Fraud, Hospital Fraud, Lack of Medical Necessity, Provider Fraud, Upcoding,

October 9, 2015

Cincinnati-based West Chester Hospital and its parent company, UC Health, agreed to pay $4.1 million to settle allegations that West Chester Hospital violated the False Claims Act by billing federal health care programs for medically unnecessary spine surgeries.  The challenged surgeries were performed between 2009 and 2013 by Dr. Abubakar Atiq Durrani, a surgeon from Mason, Ohio, who had admitting privileges at West Chester Hospital and who was arrested in July 2013 but allegedly fled the country and remains a fugitive.  The allegations first arose in a whistleblower lawsuit filed by former patients of Durrani under the qui tam provisions of the False Claims Act.  They will receive a whistleblower award of approximately $800,000 from the federal share of the settlement.  DOJ

Tagged in: FCA Federal, Hospital Fraud, Lack of Medical Necessity, Whistleblower Case, Whistleblower Rewards,

September 29, 2015

Delaware-based St. Francis Hospital agreed to pay roughly $4 million to the US and $200,000 to the State of Delaware to resolve charges it violated the False Claims Act by improperly billing Medicare and Medicaid for patients admitted into its inpatient rehabilitation unit in Wilmington, Delaware between 2007 and 2010, when admission was not medically necessary and/or the services provided did not fully qualify for reimbursement.  The settlement agreement also resolves separate allegations that St. Francis employed an individual who was excluded from participating in any Federal health care programs.  DOJ (DE)

Tagged in: FCA Federal, Hospital Fraud, Lack of Medical Necessity, Medical Billing Fraud,

September 21, 2015

Non-profit healthcare organization Adventist Health System agreed to pay $115 million to settle allegations it violated the False Claims Act by maintaining improper compensation arrangements with referring physicians and by miscoding claims.  The allegations originated in two whistleblower lawsuits filed by former Adventist hospital employees Michael Payne, Melissa Church and Gloria Pryor under the qui tam provisions of the False Claims Act.  The will receive a yet-to-be-determined whistleblower award from the government’s recovery. DOJ

Tagged in: Anti-Kickback and Stark, FCA Federal, Hospital Fraud, Medical Billing Fraud, Multiple Whistleblowers and First-to-File, Whistleblower Case, Whistleblower Rewards,

September 15, 2015

North Broward Hospital District, operator of hospitals and other health care facilities in the Broward County, Florida area, agreed to pay $69.5 million to settle allegations it violated the False Claims Act by engaging in improper financial relationships with referring physicians.  According to the government, the hospital district provided compensation to nine employed physicians that exceeded the fair market value of their services violating both the Stark Statute and False Claims Act.  The allegations first arose from a whistleblower lawsuit filed by Dr. Michael Reilly under the qui tam provisions of the False Claims Act.  Dr. Reilly will receive a whistleblower award of roughly $12 million.  DOJ

Tagged in: Anti-Kickback and Stark, FCA Federal, Hospital Fraud, Whistleblower Case, Whistleblower Rewards,

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