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Healthcare Fraud

This archive displays posts tagged as relevant to healthcare fraud.

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DOJ Reasserts the Proper Role for Agency Guidance in Fraud Cases

Posted  09/3/21
Department of Justice Logo
The Justice Department has quietly rescinded a Trump administration policy that was needlessly undermining the role of government agency guidance.  On July 1, 2021, Attorney General Merrick Garland issued a memorandum revoking what is known as the Brand Memo.  In her memo, Former Associate Attorney General Rachel Brand had set out a position that defense attorneys scrambled to use to argue for leniency or...

Catch of the Week: Florida Lab Owner Pleads Guilty to $73 Million Telemedicine Fraud Scheme

Posted  09/3/21
telemedicine doctor on computer with patient
Editor’s Note: For this week’s biggest story, the record $90 million settlement secured by a Constantine Cannon client against Sutter Health, read more here.
Healthcare fraudsters have a track record of exploiting health crises for personal gain. The COVID-19 pandemic created new telemedicine opportunities for patients to receive care without having to see doctors in person. As expected, fraudsters seized on...

Sutter Health – Medicare Advantage Fraud ($90 million)

Constantine Cannon represented whistleblower Kathy Ormsby in a False Claims Act litigation against Sutter Health and its affiliates that resulted in a $90 million settlement – the largest Medicare Advantage FCA settlement to date against a hospital system, and the second largest reported Medicare Advantage fraud settlement to date.  Ms. Ormsby, a former Risk Adjustment Factor Project Manager at Sutter Health affiliate Palo Alto Medical Foundation, alleged the Sutter Health defendants inflated the number and severity of Medicare Advantage patient diagnoses, manipulated patient records, ignored audit “red flags,” and engaged in other misconduct to increase patient risk scores and obtain Medicare Advantage payments to which they were not entitled.  In Spring 2019, the Government intervened in Ms. Ormsby’s case as to PAMF, and Ms. Ormsby continued to pursue her claims against the other Sutter Health affiliates on a non-intervened basis. This settlement resolves all claims and follows Sutter’s unsuccessful effort to dismiss both the complaints.  Read more: Press Release; Whistleblower Insider.

August 30, 2021

Northern California healthcare provider Sutter Health and its affiliated entities will pay $90 million to resolve a False Claims Act case initially filed by whistleblower Kathy Ormsby alleging that defendants submitted unsupported diagnosis codes for patients enrolled in Medicare Advantage.  Sutter contracts with Medicare Advantage Organizations to provide care to Medicare Advantage beneficiaries enrolled in their plans, and allegedly caused those MAOs to submit to Medicare inaccurate and invalid diagnosis codes that inflated the risk scores of those beneficiaries and were not supported by the medical records, thereby resulting in overpayments by CMS.  Sutter also allegedly failed to take sufficient corrective action when it became aware of the submission of these unsupported diagnosis codes.  Sutter also entered into a five-year corporate integrity agreement.  Sutter previously entered into a partial settlement of $30 million, which will be credited against the $90 million total settlement.  DOJ; USAO ND Cal

Managed Care Risk Adjustment Enforcement Continues with Sutter Health Settlement: Constantine Cannon Client Secures Largest Ever Medicare Advantage Settlement by a Hospital

Posted  08/30/21
Sutter Health will pay the Government $90 million under the False Claims Act for allegedly submitting inaccurate and unsupported medical information on tens of thousands of patients.  The settlement in a case brought by a whistleblower represented by Constantine Cannon, together with co-counsel Keller Grover and Kleiman Rajaram, is the largest Medicare Advantage FCA settlement against a hospital system, and the...

August 27, 2021

John Peter Smith Hospital (JPS) in Texas has agreed to pay more than $3.3 million to resolve a qui tam suit filed by its former Director of Compliance, Erma Lee, which alleged that the hospital routinely applied billing modifiers that essentially double-billed federal healthcare programs for certain aspects of patients’ care.  Even after raising the issue internally, JPS allegedly failed to reimburse payors, prompting Lee to file the case in 2018.  For doing so, Lee will receive over $900,000 of the settlement proceeds.  USAO NDTX

August 26, 2021

Mental health and addiction services provider Connections Community Support Programs, Inc. has consented to the entry of judgment ordering payment of $15.3 million to resolve claims that it billed federal healthcare programs for mental health services performed by individuals without required professional qualification, billed using incorrect procedure codes, and failed to keep proper records regarding controlled substances.  Connections has filed for bankruptcy, and the government recovery will be limited by the availability of funds in the bankruptcy estate.  The settlement resolves claims brought in a qui tam lawsuit by two former Connections employees.  USAO Del

August 25, 2021

A California-based provider of home respiratory services and durable medical equipment has agreed to pay $3.3 million to the United States and States of California and Nevada to settle allegations of defrauding Medicare and Medicaid.  The claims against SuperCare Health, Inc. were brought in a 2018 qui tam suit by respiratory therapist Benjamin Martinez, who alleged that the provider billed for non-invasive ventilators (NIVs) that were no longer needed or being used by patients.  CA AG; USAO CDCA

Medically Unnecessary Procedures Harm Patients, Raise U.S. Healthcare Costs, Atlantic Feature Emphasizes

Posted  08/20/21
surgeons operating on patient under bright lights
Unnecessary procedures have long plagued the U.S. healthcare system, costing taxpayers billions and subjecting thousands of patients to invasive procedures that sometimes do more harm than good. For decades, various government actors have acknowledged the problem.

Why then is it so difficult to prevent unnecessary procedures in the U.S.?

Reporter Chris Outcalt recently pondered in a piece for The Atlantic. The...

Catch of the Week: Telemedicine Company Owner Charged in $784 Million Kickback Scheme

Posted  08/20/21
Doctor on computer with patient discussing medicine
Underscoring the fraud risks associated with the government’s continued expansion and loosening of restrictions on telehealth, the U.S. Department of Justice recently announced that a grand jury in New Jersey has returned a superseding indictment against the Florida owner of multiple telemedicine companies, referred to by DOJ prosecutors as the Video Doctor Network, for allegedly participating in a massive Medicare...
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