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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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February 7, 2019

Six people associated with a string of substance abuse treatment centers have been indicted for defrauding Ohio's Medicaid program of over $31 million. Ryan Sheridan, the owner and operator of the businesses, along with Jennifer Sheridan, Kortney Gherardi, Lisa Pertee, Thomas Bailey, and Arthur Smith, allegedly submitted claims that were false on a number of fronts, including but not limited to: billing without proper documentation, for medically unnecessary services, provided by unqualified persons, and upcoded to a more costly service. Altogether, 134,744 false claims were submitted for more than $48.5 million in services. USAO NDOH

February 7, 2019

A former bus driver with the New York Metropolitan Transit Authority has been sentenced to 20 months in prison for defrauding the authority's health benefit plan of $2.8 million. Enver Kalaba, who was recruited into the scheme by former bus driver Christopher Frusci, worked on behalf of an unnamed company to pay bribes to fellow MTA employees in exchange for medically unnecessary prescription compounded medications. For each prescription for medications such as pain creams, scar creams, and metabolic supplements, Kalaba and Frusci paid $100. As part of his sentence, Kalaba must now forfeit $138,630 in fraudulent earnings and pay $2.9 million in restitution. Frusci is scheduled to be sentenced next month. USAO NJ

February 4, 2019

Compounding pharmacy Pentec Health, Inc., which sells a drug Proplete for nutrition support for patients with end stage renal disease, has agreed to pay $17 million to settle claims under the False Claims Act.  Pentec was alleged to bill federal healthcare programs for product wasted during the compounding of Proplete, and for Proplete that was not medically necessary or was not actually received by patients, routinely waiving patient copays and deductibles to induce the prescription of the drug.  Pentec also entered into a corporate integrity agreement and will be excluded from participation on federal healthcare programs.  The case was initiated by whistleblower Jean Brasher, a former employee of Pentec, who will receive an undisclosed share of the settlement. USAO EDPA

January 29, 2019

Two doctors and a health clinic owner in the Houston area have each been sentenced to decades in prison following their convictions for Medicare fraud. In one case involving three defendants—clinic owner Ann Shepherd, doctor John Ramirez, and Yvette Nwoko—Medicare paid over $17 million in fraudulent claims resulting from false certifications related to services not medically necessary or properly provided. Defendants Shepherd was sentenced to 30 years in prison, and ordered to pay $20 million; Ramirez was sentenced to 25 years in priosn and ordered to pay $26 million; Nwoko awaits sentencing. In a second case, related case, doctor Anh Do was sentenced to three years in prison and ordered to pay almost $2 million in restitution on similar charges. DOJ 1; DOJ 2

January 28, 2019

Ademola O. Adebayo, of Odessa, FL, was convicted for his role in a massive compounding pharmacy fraud scheme through which he submitted false and fraudulent claims for compounded drugs and other prescription medications that were not medically necessary, never provided, or both. The evidence established that in his role as the pharmacist at A to Z Pharmacy, now-defunct, Adebayo conspired to submit or cause the submission of claims that often amounted to several thousands of dollars for a single tube of pain or scar cream. When the fraud was uncovered, Adebayo became the straw owner of Havana Pharmacy & Discount in Miami, where Adebayo and his co-conspirators continued the fraud. Adebayo personally benefited from the fraud and received $1.5 million. DOJ

January 22, 2019

Walgreens Co. will pay the U.S. and the State of Wisconsin $3.5 million to settle a case under the False Claims Act alleging that the retail pharmacy routinely dispensed stimulant medications to Wisconsin Medicaid beneficiaries without first verifying that the prescribing physician ordered the medication for medically appropriate treatment, such as treatment for attention deficit disorder. The case was initiated by unidentified whistleblowers, who will receive a share of the settlement to be determined. USAO EDWI

December 21, 2018

Providence, Rhode Island-based Professional Ambulance, Inc., will pay $300,000 to resolve claims that it billed Medicare and Medicaid for ambulance services that were not medically necessary.  Specifically, the company transported dialysis patients, who require regular trips to and from a treatment facility, but many of whom were not eligible to travel by ambulance because they were sufficiently mobile.  USAO RI

Catch of the Week — Hospice Provider to Pay $6 Million to Settle False Claims Act Suit

Posted  12/21/18
SouthernCare, Inc., a hospice provider owned by Curo Health Services, has agreed to pay the federal government nearly $6 million dollars to settle a lawsuit alleging that the company defrauded Medicare by billing medically unnecessary hospice care. The fraud was unearthed by two whistleblowers formerly employed by the company, who filed suit under the qui tam provisions of the False Claims Act, where they will share...

December 20, 2018

Pain specialist Dr. Jonathan Daitch, a principal in Ft. Myers-based Advanced Pain Management Specialists, P.A., has agreed to pay more than $1.7 million to resolve allegations that he violated the False Claims Act.  Dr. Daitch caused Medicare and Tricare to be billed for medically-unnecessary urine drug testing performed at Advanced Pain's in-house laboratory.  In addition, Daitch received kickbacks for anesthesia services.  A co-owner of Advanced Pain, Dr. Michael Frey, previously agreed to pay $2.8 million to settle similar claims.  USAO MD Fla

December 19, 2018

A vascular surgeon and his practice group, Dr. Irfan Siddiqui and the Heart and Vascular Institute of Florida (HAVI), have agreed to pay $2.23 million to settle a False Claims Act brought by a whistleblower, Lois Hawks, who had been a patient of the doctor.  Defendants were alleged to have submitted false claims for vein ablation services that were not medically necessary, were performed by unqualified personnel, or were based on medical records containing false diagnoses and symptoms.  In addition, defendants were alleged to have upcoded evaluation and management service claims.  Ms. Haws will receive a relator's share of $446,000USAO MDFL
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