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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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June 11, 2019

Two additional co-defendants in a recently reported home health fraud case have been sentenced to 6-10 years in prison and ordered to pay over $4.3 million each for their involvement.  Angela Avetisyan and Ashot Minasyan, the co-owners and operators of Fifth Avenue Home Health, paid kickbacks to Marina Merino and other patient recruiters to bring Medicare patients to a clinic owned by Robert Glazer.  In exchange, they received referrals from Glazer’s clinic for home health services that were allegedly medically unnecessary.  DOJ; USAO CDCA

DOJ Catch of the Week — Dr. Joseph Galichia

Posted  05/31/19
Paper Ripped Uncovering Medical Necessity Wording
This week's DOJ Catch of the Week goes to Kansas cardiologist Joseph Galichia. Yesterday, he agreed to pay $5.8 million to resolve allegations that he and his company, Galichia Medical Group, violated the False Claims Act by billing federal health care programs for medically unnecessary cardiac stent procedures. This is the government's third False Claims Act settlement with Dr. Galichia. Which may explain why he also...

May 30, 2019

HyperHeal Hyperbarics, an oxygen therapy facility in Maryland, has agreed to pay over $400,000 to settle whistleblower allegations filed under the False Claims Act.  In their 2016 qui tam suit, former employees Lesa Schrum and Juliette Skelton alleged that from 2013 to 2014, HyperHeal and its part-owner Eric Shapiro billed TRICARE for medically unnecessary services, services performed without physician supervision, or services that weren't ever performed.  As part of the settlement, Schrum and Skelton will receive $74,635.25.  USAO MD

May 30, 2019

Joseph P. Galichia, a cardiologist in Wichita, Kansas, will pay $5.8 million to resolve allegations under the False Claims Act that he and his practice, Galichia Medical Group, P.A., implanted cardiac stents in patients who did not need them, and billed Medicare, the Defense Health Agency, and the Federal Employees Health Benefits Program for these medically unnecessary procedures. Galichia will also be excluded from participating in federal healthcare programs for three years. The case was initiated by a whistleblower, Aly Gadalla, M.D., who filed a qui tam complaint.  Dr. Gadalla will receive a whistleblower reward of $1.16 million.  This is the third time Galichia had settled FCA claims against him and his practice. DOJ; USAO Kan

Intermountain Settles Dispute Pending Before Supreme Court, Leaving 9(b) Ambiguity Unresolved

Posted  05/24/19
Doctor Holding Heart in Palms
Earlier this month, a Utah-based hospital chain announced it would settle whistleblower Dr. Gerald Polukoff’s case alleging the hospital performed unnecessary heart surgeries on Medicare patients, thereby overcharging the federal government in violation of the False Claims Act (FCA). Defendant Intermountain Health, the largest healthcare provider in the Intermountain West, had petitioned the U.S. Supreme Court to...

Question of the Week — Should the CEO Be Held Accountable?: Lessons from the Insys verdict.

Posted  05/10/19
By Jessica T. Moore
Handcuffed business-leader walking through jail.
In a shocking first, a federal jury has convicted an opioid-company CEO and other top executives of a criminal racketeering conspiracy. Insys founder and chairman John Kapoor and four other executives bribed doctors to overprescribe a highly addictive fentanyl painkiller, and ran a phony call-center to defraud insurance companies into paying for the expensive drug. Although the company itself had already paid over...

April 30, 2019

The former CEO of hospital chain Health Management Associates LLC, Gary D. Newsome, has agreed to pay $3.46 million to resolve claims in a whistleblower lawsuit that he personally caused HMA to submit false claims to federal healthcare programs in violation of the False Claims Act.  Newsome was alleged to have caused HMA to pressure emergency department physicians to increase inpatient admissions without regard to medical necessity, so that the hospital chain could bill for more costly inpatient services.  In addition, Newsome was alleged to have caused HMA to make bonus payments to emergency department physicians, and contract concessions to the company, EmCare, that provided emergency department physician staffing, to increase inpatient admissions.  Newsome was the CEO from 2008 through 2013, prior to HMA's acquisition by Community Health Systems Inc.  HMA settled related claims in September 2018, and EmCare settled related claims in December 2017.  Two whistleblowers, Jacqueline Meyer, a former employee of EmCare, and J. Michael Cowling, a former employee of HMA, will receive approximately $725,000 from this settlement.  DOJ

April 24, 2019

Two executives of Arriva Medical, LLC, a mail-order diabetic testing supply company acquired by Alere, Inc. in 2011, will pay a total of $1 million to settle claims that they caused Arriva to submit false claims to Medicare by supplying patients with free or no cost home blood glucose meters, waiving patient copayments, and billing for medically unnecessary home blood glucose meters.  USAO MD TN

April 9, 2019

A number of telemedicine and durable medical equipment companies, the principals of those companies, and three healthcare providers, were charged with submitting over $1.7 billion in false claims in a scheme to pay unlawful kickbacks and bribes from DME companies in exchange for the referral of Medicare beneficiaries by medical professionals working with fraudulent telemedicine companies for medically unnecessary DME including back, shoulder, wrist and knee braces.  DOJ; USAO MD FL; USAO NJ; USAO SC.
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