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Hospital Fraud

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April 6, 2022

Florida hospital chain BayCare Health System Inc. will pay $20 million to resolve claims that the company knowingly caused false claims for federal Medicaid matching funds to be submitted to the United States by making improper, non-bona fide cash donations to the Juvenile Welfare Board of Pinellas County (JWB) knowing that the funds would be transferred by JWB to the State of Florida’s Agency for Health Care Administration for Florida’s Medicaid Program, which would trigger a corresponding federal matching payment.  The prohibition on non-bona fide donations ensures that states are paying a share of Medicaid payments; the non-bona fide donations increased Medicaid payments received by BayCare without any actual expenditure of state or local funds and enabled BayCare to recoup its original donations to JWB and also receive federal matching funds. The case was initiated with a qui tam complaint filed by Larry Bomar, who will receive $5 million as an award for initiating the whistleblower action. DOJ; MD FL

As Whistleblowers and Quality Care Advocates, Hospitalists are the Conscience of Healthcare

Posted  02/28/22
By Mary Inman, Ari Yampolsky
Thursday, March 3, 2022 is National Hospitalist Day, a day we recognize the contributions of the specialist care doctors and other professionals who provide quality care to sick and vulnerable patients in a hospital.  As the fastest growing specialty in modern medicine, hospitalists are a critical part of the nation’s health care service delivery system. Less noted but no less important, hospitalists also play a...

Top 5 Reasons Why Nurses Make Great Whistleblowers

Posted  02/22/22
By Edward Baker
hospital staff
Nurses are rightly getting a lot of attention lately for the courageous and essential role they are playing on the front-line during the COVID-19 pandemic.  Whether in hospitals, nursing homes, hospices, or as home health workers, nurses are finally “learning what they are worth,” even as private equity firms seek to profit from nurses’ increased wage-earning power.  As reported by STAT, Congress is now...

February 9, 2022

The Catholic Medical Center (CMC) will pay $3.8 million for violations of the False Claims Act and the Anti-Kickback Statute. Over a ten-year period, the CMC provided call coverage services to a cardiologist, for free, in exchange for lucrative referrals to their hospital, resulting in receipt of millions of dollars for services and medical procedures. USAO NH

January 20, 2022

A three-year-long kickback scheme effectuated by a hospital executive and seven doctors will net the DOJ a $1.1 million settlement and their continued cooperation in the investigation of and litigation against other parties. The Stark Law and Anti-Kickback Statute violations occurred over a three-year period, wherein management service organizations (MSOs) paid volume-based commissions kickbacks for ordering laboratory tests from Rockdale Hospital d/b/a Little River Healthcare, True Health Diagnostics LLC, and Boston Heart Diagnostics Corporation. Jaspaul Bhangoo, M.D., Robert Megna, D.O., Baxter Montgomery, M.D., Murtaza Mussaji, D.O., David Sneed, D.O., Kevin Lewis, D.O., and Angela Mosley-Nunnery, M.D. will all contribute to the settlement. Additionally, Richard Defoore, former CEO of Jones County Regional Healthcare d/b/a Stamford Memorial Hospital, also agreed to pay into the settlement fund for his contribution to the scheme. USAO EDTX

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 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 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

July 19, 2021

Prime Healthcare Services, one of the largest hospital systems in the nation, its founder and CEO Dr. Prem Reddy, and interventional cardiologist Dr. Siva Arunasalam have agreed to pay $37.5 million to resolve two suits filed by former executive Martin Mansukhani, and former employees Marsha Arnold and Joseph Hill.  In violation of the federal and California False Claims Acts, certain Prime hospitals had allegedly submitted inflated invoices to Medi-Cal and other government health programs, or submitted claims to Medi-Cal and Medicare under Arunasalam’s provider number for services provided by an excluded physician.  Additionally, in acquiring Arunasalam’s physician practice and surgery center, Prime allegedly paid above fair market value for referrals from Arunasalam to one of their hospitals.  For being the first to file, one of the whistleblowers, Mansukhani, will receive a relator’s share of nearly $10 million.  CA AG; USAO CDCA

July 2, 2021

An Ohio-based hospital system that has since been acquired by the Cleveland Clinic Foundation has agreed to pay over $21 million to resolve alleged violations of the Anti-Kickback Statute, Physician Self-Referral Law, and False Claims Act.  Between 2010 and 2016, Akron General Health System (AGHS) allegedly paid area physician groups far above fair market value in order to induce referrals, then submitted claims arising from those illegal referrals to federal healthcare programs.  The settlement resolves a qui tam suit brought forth by former internal audit director at AGHS, Beverly Brouse, and Ethical Solutions LLC.  DOJ
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