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Healthcare Fraud

This archive displays posts tagged as relevant to healthcare fraud.

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August 19, 2021

Nevada Advanced Pain Specialists agreed to pay $1 million to resolve allegations that it submitted false claims for confirmatory urine drug testing performed without regard to the results of presumptive tests that had been performed. The allegations were first brought in a qui tam lawsuit filed by an whistleblower Omni Healthcare, Inc., which will receive a relator’s share of $150,000 of the settlement.  USAO MA

Court says that fraudsters who violate rules they later claim are unclear may not violate the False Claims Act

Posted  08/19/21
Red and yellow pills scattered on hundred dollar bills
Last week, the Seventh Circuit Court of Appeals, the federal appellate court for Illinois, Indiana, and Wisconsin decided U.S. ex rel. Yarberry v. Supervalu, an important decision that may lead more unscrupulous government contractors to help themselves to public funds to which they are not entitled.  Unless the Supreme Court or Congress steps in to correct the Seventh Circuit’s errors, the government may have...

August 17, 2021

Following a voluntary self-disclosure to authorities, Blessing Hospital in Quincy, Illinois, has agreed to pay $2.82 million to resolve allegations that it submitted false claims for the facility component of medically unnecessary cardiac catheterization procedures.  The federal government will receive $2.6 million of the settlement, with the remainder going to Illinois, Iowa, and Missouri.  USAO CD IL

August 17, 2021

Bristol Myers Squibb (BMS) has agreed to pay $75 million to a resolve a whistleblower’s allegations that it underpaid drug rebates owed to state Medicaid programs nationwide.  In order to ensure states pay competitive prices, federal law requires pharmaceutical companies to return a portion of payments from state Medicaid programs, calculated based on the average price paid by drug wholesalers.  The misconduct involved BMS underreporting their drugs’ Average Manufacturer’s Price by treating wholesaler fees as discounts, thus decreasing the amount it supposedly owed to the healthcare programs.  CA AG; NJ AG

August 12, 2021

United Behavioral Health and United Healthcare Insurance Co. will pay $2 million in penalties to resolve claims that the insurer unlawfully denied coverage for mental health and substance use disorder treatment in violation of laws that require health insurance plans to cover mental health and substance use disorder treatment the same way they cover physical health treatment. New York and the federal Department of Labor alleged that United reduced allowed amounts for mental health and substance abuse services provided by non-physicians, but not for medical treatments provided by non-physicians, and conducting utilization reviews for psychotherapy that were not conducted at the same rate for medical/surgical services.  In addition the penalty, United agreed to pay $13.6 million to affected participants and beneficiaries.  DOL; NY

August 9, 2021

The owners of North Carolina compounding pharmacy Wellcare Compouding, David Tsui and Lois Tsui, paid $1.1 million to resolve allegations that they violated the False Claims Act by submitting false claims for payment to the TRICARE program in 2014 and 2015.  The government alleged that Wellcare made improper payments to physicians and “marketers” in violation of the Anti-Kickback Statute and encouraged medically unnecessary prescriptions consisting of high-margin ingredients in order to maximize the pharmacy’s reimbursement. David Tsui had been convicted of healthcare fraud in 2009 and was excluded from participation in federal healthcare programs; the government alleged that his involvement and ownership was intentionally concealed.  USAO MD NC

August 6, 2021

Maryland-based National Spine & Pain Center (NSPC) and its affiliate, Physical Medicine Associates, Ltd. (PMA), have agreed to pay $5.1 million to Medicare and enter into a non-prosecution agreement to settle a criminal fraud investigation.  In violation of the Anti-Kickback Statute, NSPC and PMA had conspired with a now-defunct California-based genetics testing company called Proove Biosciences to have Proove pay illegal kickbacks to NSPC and PMA physicians in exchange for a certain volume of test referrals.  Nine individuals have been charged in connection with the scheme.  USAO SDCA

August 6, 2021

A county in California and a county medical center have agreed to pay $11.4 million to resolve allegations of improperly billing a federal healthcare program between 2013 and 2017.  According to whistleblower Felix Levy, a former employee of San Mateo County Medical Center (SMMC), San Mateo County and SMMC billed Medicare for uncovered hospital stays for patients that were admitted without regard to medical necessity.  USAO NDCA

Media Coverage of Government Intervention in Kaiser Medicare Advantage Suits: LA Times says Cases Point to a “Massive Fraud Problem in Medicare”

Posted  08/6/21
Headshots of attorneys Edward Baker, Mary Inman, and Michael Ronickher
As we announced last week, the U.S. Department of Justice gave notice that it was intervening in six different False Claims Act lawsuits against Medicare Advantage organization Kaiser Permanente and its affiliated entities, including a whistleblower lawsuit filed by Constantine Cannon’s whistleblower client, James Taylor, M.D.  The government’s decision received extensive coverage in the media, with Los Angeles...

August 5, 2021

Ascension Michigan and related hospitals, which allegedly billed federal healthcare programs for services performed by a gynecologic oncologist that were not medically necessary or rendered as represented, has agreed to pay $2.8 million to resolve their liability under the False Claims Act.  The settlement resolves claims from a 2017 qui tam suit by whistleblowers Pamela Satchwell, Dawn Kasdorf, and Bethany Silva-Gomez, that Ascension knowingly submitted claims for medically unnecessary hysterectomies and chemotherapy, and unrendered evaluation and management services.  Spurred by patient complaints, Ascension launched an internal investigation, ultimately self-disclosing the misconduct to the government in 2018.  As part of the settlement, Satchwell, Kasdorf, and Silva-Gomez will share in a $532,000 award.  USAO EDMI
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