Healthcare Fraud

July 7, 2020

Florida Cancer Specialists & Research Institute, LLC (FCS) has agreed to return more than $2.3 million in overcharges to the VA after a successful qui tam action by a former Claims Resolution Specialist with FCS, Marianne Parker.  Parker’s complaint instigated a government investigation that found that an error in the VA’s billing system had led the agency to pay the full amount billed by FCS for certain physician-administered drugs provided to veterans, rather than at the Medicare rate mandated by the Code of Federal Regulations.  For alerting the government to the discrepancies, Parker will receive a 20% share of the funds.  USAO MDFL

July 1, 2020

Novartis Pharmaceuticals Corporation will pay a total of $678 million to resolve a case brought by a whistleblower, Oswald Bilotta, alleging that between 2002 and 2011 the pharmaceutical company violated the Anti-Kickback Statute and False Claims Act by providing doctors with cash payments and luxury travel and meals to induce them to prescribe Novartis cardiovascular and diabetes drugs reimbursed by federal healthcare programs.  The total settlement consists of $591.4 million as federal FCA damages, $48.2 million as state FCA damages for Medicaid false claims submitted to 28 states and the District of Columbia, and $38.4 million as forfeiture under the Anti-Kickback Statute.  The whistleblower award has not yet been determined.  In addition to the monetary settlement, Novartis entered into a Corporate Integrity Agreement obligating the company to, among other things, significantly reduce its volume and spending on paid speaker programs.  DOJ; USAO SDNY; CA AG; MI AG; NY AG

July 1, 2020

Novartis Pharmaceuticals Corporation will pay $51.25 million to resolve claims that it unlawfully funneled money to three different foundations – The Assistance Fund, the National Organization for Rare Disorders, and the Chronic Disease Fund – so that those organizations could fund co-payments owed by Medicare beneficiary patients prescribed the Novartis drugs Gilenya (for multiple sclerosis) and Afinitor (for renal cell carcinoma and certain pancreatic cancers).  The payments were alleged to be in violation of the Anti-Kickback Statute and False Claims Act.  USAO Mass; DOJ

July 1, 2020

Genetic testing company Agendia, Inc., which offers the MammaPrint test analyzing genes within breast cancer tumors to predict recurrence, will pay $8.25 million to resolve claims of Medicare fraud in a case brought by a whistleblower under the False Claims Act.  Agendia was alleged to have conspired with hospitals to delay the performance of MammaPrint tests for patients discharged from those hospitals.  Under the Medicare 14-Day Rule in effect during the relevant time period, Agendia was allowed to bill Medicare directly for the test if it was performed more than 14 days after the patient was discharged from the hospital; if the test was performed within 14 days of discharge, then it would be billed through the hospital.  If Agendia received a physician’s order for a Medicare patient within 14 days of the patient’s discharge, it would either cancel the order and require the physician to resubmit it, or otherwise improperly delay the test and claim it was ordered and performed on a later date.  The whistleblower was a former employee of a Kentucky hospital, Mercy Health- Lourdes, which worked with Agendia to allow it to separately bill Medicare for the test, including by holding tissue specimens for 14 days or longer after patients were discharged. The hospital previously paid $211,039 to settle its liability.  No reward amount for the whistleblower was made public.  USAO WDKY  

June 30, 2020

Clifford P. Shomake and Kimberly Clyde “Casey” Conner, the owners of Guam Medical Transport, were sentenced to 6 years and 5.25 years, respectively, following their guilty pleas to charges arising from their conspiracy to defraud Medicare and TRICARE by submitting claims for reimbursement for medically unnecessary ambulance services that GMT provided to patients with end stage renal disease, despite knowing that the individuals did not qualify for ambulance transport under applicable regulations.  Defendants admitted that the conspiracy resulted in improper payments to GMT of approximately $10.8 million, and restitution in that amount was also ordered.  DOJ

June 30, 2020

Ophthalmic Consultants, P.A. and its principal Robert K. Snyder have agreed to pay $4.8 million to resolve claims that they unlawfully billed federal healthcare programs for the drugs ranibizumab (Lucentis®) and aflipercept (Eylea®).  While the drugs are sold in single-use vials, defendants used single vials to provide doses to multiple patients, allowing them to obtain excessive reimbursement from Medicare, TRICARE, and the Federal Employees Health Benefits Program.  USAO MD FL