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Lack of Medical Necessity

This archive displays posts tagged as relevant to fraud arising from medically unnecessary healthcare services. You may also be interested in our pages:

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December 14, 2018

Crossroads Hospice of Kansas has agreed to pay $300,000 for violating the Kansas False Claims Act. Under that law, once a healthcare provider is alerted to charges improperly submitted to the state's Medicaid program, it is obligated to refund the reimbursement in a timely manner or risk prosecution. In the case of Crossroads, the provider had failed to refund money paid on behalf of improperly certified beneficiaries. KS AG

December 13, 2018

Hospice care provider SouthernCare, Inc. has agreed to pay $5,863,426 for submitting fraudulent claims to Medicare between 2009 to 2014. Under Medicare's eligibility rules, in order for hospice care to be reimbursed, a patient must have a life expectancy of six months or less as certified by a physician, and terminal illnesses must be documented with appropriate records. However, according to qui tam complaints by former employees Dawn Hamrock and Patricia Beegle, SouthernCare billed Medicare for care provided to patients who were not Medicare eligible or who had no proof of Medicare eligibility. As part of the settlement, Hamrock and Beegle will share a $1.1 million whistleblower reward. USAO EDPA

December 3, 2018

Feng Qin, M.D., a vascular surgeon who in 2015 settled claims that he performed medically-unnecessary vascular surgeries, has again been charged with such unlawful practices.  As reported by an unidentified whistleblower who brought a case under the False Claims Act, Qin routinely scheduled patients for surgeries months in advance, regardless of whether there was a justifiable clinical reason for the surgery.  At times, Qin would alter medical records.  Qin would then bill Medicare for these procedures, despite his knowledge that procedures on patients that are not medically reasonable and necessary are not covered by Medicare.  USAO SDNY

November 16, 2018

A New Jersey-based doctor, Dr. Bernard Ogon, has been charged with participating in a compound pharmacy fraud that caused over $20 million in losses to health care benefit programs, including $3 million in losses to TRICARE. In exchange for a per-prescription payment, Ogon allegedly signed prescriptions that were pre-filled by telemedicine companies on behalf of patients he never saw. On multiple occasions, the prescriptions were for pain and scar creams that were not medically necessary, and were in fact exorbitantly expensive when made by a compound pharmacy. Ogon was also accused of writing prescriptions for patients in states that he was not licensed to practice in; if convicted, he faces a maximum of 10 years in prison. USAO NJ

November 14, 2018

After pleading guilty last year, the owner of two health clinics in Detroit has been sentenced to 160 months in prison and ordered to pay over $6 million for defrauding Medicare. Along with multiple co-defendants, Jacklyn Price allegedly took part in a scheme to bill Medicare for services that were obtained through kickbacks, not medically necessary, not actually provided, or provided by an unlicensed practitioner. Her co-defendants, Millicent Traylor, Muhammad Qazi, and Christina Kimbrough, were all sentenced in September. DOJ

November 6, 2018

An Indiana-based dental care practice and admin support company have agreed to pay a total of $5.139 million to settle allegations they violated the federal and Indiana state False Claims Acts. According to whistleblower and qui tam plaintiff Dr. Jihaad Abdul-Majid, between 2009 and 2013, ImmediaDent of Indiana, LLC and Samson Dental Partners, LLC allegedly billed Indiana's Medicaid program for procedures that were either upcoded (i.e. represented to be more serious and more expensive than they actually were), were not actually performed, or were not medically necessary. Samson Dental Partners is additionally accused of violating Indiana’s law prohibiting the corporate practice of dentistry. Because the companies refused oversight proposed during settlement, they have now been classified as "high risk" to federal healthcare programs. IN AG; USAO WDKY

November 2, 2018

Metropolitan Retina Associates, Inc. and its owner, Dr. Kenneth S. Felder, have settled a False Claims Act investigation by agreeing to pay $2,064,559 for Medicare and Medicaid fraud. As part of the settlement, the New York-based ophthalmology practice admitted and accepted responsibility for submitting claims involving medically unnecessary and improperly documented fluorescein angiograms, as well as ultrasounds of the eye. USAO SDNY

October 31, 2018

A London-based doctor has been sentenced to 42 months in federal prison for defrauding Medicare, Medicaid, and private insurers. The doctor, Dr. Anis Chalhoub, was convicted in April of implanting over 200 medically unnecessary pacemakers in patients at St. Joseph London hospital, reportedly even pressuring patients and giving them misleading information so that they would agree to the procedures. He is ordered to pay $257,515 in restitution to Medicare, Medicaid, and private insurers, as well as a $50,000 fine. USAO EDKY

October 30, 2018

Four people connected to a Texas-based home health agency have been found guilty of fraudulently obtaining $3.7 million in reimbursements from Medicare and Medicaid. Despite being previously banned from participating in any federal healthcare reimbursement programs, Celestine Okwilagwe and Paul Emordi co-owned and operated a Medicare and Medicaid provider in the Dallas area called Elder Care. Adetutu Etti, the provider's administrator, was recruited to falsely certify that someone else was the owner, and Okwilagwe's wife, Loveth Isidaehomen, was recruited to sign checks. Some of the claims that were eventually reimbursed by Medicare were also found to be for services that were not medically necessary. DOJ

October 23, 2018

Vascular Access Centers LP (VAC) and its 20+ related corporations in multiple states have agreed to pay $3.825 million over five years to settle whistleblower-brought allegations that VAC took part in an illegal patient referral kickback scheme and fraudulently billed Medicare for certain non-reimbursable procedures. The alleged fraud violated the Anti-Kickback Statute and False Claims Act and involved regularly scheduling, performing, and billing Medicare for certain vascular access procedures for End Stage Renal Disease (ESRD) beneficiaries that were not routinely necessary. Two whistleblowers will share in the relator's share of $612,000. DOJ; USAO EDLA; USAO SDNY
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