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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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October 17, 2019

Five home health providers in Iowa and South Dakota have been ordered to pay a combined $3.1 million for submitting false claims to Medicare.  Affiliates of Minnesota-based Welcov Healthcare LLC allegedly billed Medicare for therapy services that were not provided by skilled employees or not medically necessary.  Sergeant Bluff Healthcare, LLC will pay over $1.2 million, Logan Healthcare, LLC and Elk Point Healthcare #1, LLC will each pay over $775,000, Red Oak Healthcare, LLC will pay over $228,000, and Flandreau Healthcare 2, LLC will pay about $116,000.  USAO NDIA

October 15, 2019

Otolaryngologist Dr. Tracey Wellendorf has agreed to pay $1 million to resolve allegations of violating the False Claims Act in at least 115 procedures billed to Iowa Medicaid.  The alleged misconduct occurred between 2014 and 2015 and involved endoscopic sinus surgeries that were either medically unnecessary or incorrectly coded.  USAO NDIA

October 9, 2019

The largest operator of kidney dialysis clinics in the United States has agreed to pay $5.2 million to resolve a lawsuit alleging it submitted false claims to Medicare for excessive and unnecessary immune tests.  From 2013 to 2010, Fresenius Medical Care Holdings, Inc. allegedly billed Medicare for Hepatitis B surface antigen tests it performed on patients already known to be immune, at a frequency well above that established by Medicare.  For exposing the alleged False Claims Act violations, former employee Christopher Drennen will receive a 27.5% share of the recovery.  USAO MA

October 4, 2019

Florida man Brock Lovelace has been sentenced to nearly six years in federal prison following his conviction at trial on charges related to his payment of kickbacks to medical clinics in the Miami area in exchange for the clinics providing him with DNA samples for submission to a DNA testing laboratory between 2013 and 2014.  Lovelace requested that the medical clinics collect the DNA of all the patients who visited the clinics; in turn, the clinics provided food and other inducements to beneficiaries to get them to visit.  Lovelace then submitted the DNA swabs to a testing lab, which billed Medicare.  The patients were not provided with the results of the DNA testing, and typically did not have any medical need for the DNA testing.  Lovelace was previously sentenced to 14 years in prison on other healthcare fraud charges; he will serve the present sentence consecutively.  DOJ

October 4, 2019

Southern California-based Retina Institute of California Medical Group (RIC), its former CEO, and several of its physicians have agreed to pay the State of California and United States $6.65 million to settle alleged violations of state and federal False Claims Acts.  According to former administrators Bobbette Smith and Susan Rogers, between 2006 and 2017, the ophthalmology group improperly billed Medicare and Medicaid for unnecessary and unperformed eye exams, upcoded simple exams using codes normally reserved for emergency conditions, and waived mandatory co-payments and deductibles to induce patient referrals.  Smith and Rogers will receive a relator’s share, which remains to be determined.  USAO CDCA

September 26, 2019

Physician Philippe R. Chain will pay $300,000 to resolve allegations that he caused the submission of false claims to Tricare while working for telemedicine company CallMD. Chain allegedly issued and approved prescriptions for compounded medications, many of which were not medically necessary, without speaking to, examining, or otherwise having a physician-patient relationship with the patients.  USAO CT

Catch of the Week — Texas Hospital Exec Sentenced to 10 Years in Prison for Medicare Fraud

Posted  09/18/19
On Monday, a federal judge in Houston sentenced Starsky Bomer, the former CFO and COO of Atrium Medical Center and Pristine Healthcare, to ten years in prison for his role in a Medicare fraud scheme that bilked the government of $16m.  Bomer was convicted by a jury in October of last year.  His co-conspirator, Dr. Sohail R. Siddiqui, took a plea deal in 2017 and is serving five years in prison. Bomer will do time...

Catch of the Week – South Florida Health Care Facility Owner Sentenced to 20 Years in $1.3 Billion Fraud - The Largest Health Care Fraud Scheme Ever Charged by the DOJ

Posted  09/13/19
Philip Esformes, 50, of Miami Beach, Florida, was sentenced to 20 years in prison for his role in a decades-long billion-dollar scheme to submit fraudulent claims to Medicare and Medicaid both for services deemed medically unnecessary and services that were medically necessary but that he did not provide.  Esformes personally pocketed $37 million from this scheme to fund his lavish lifestyle, while leaving elderly...

September 12, 2019

Following his conviction earlier this year, Philip Esformes was sentenced to 20 years in prison for his role in orchestrating a Medicare and Medicaid fraud scheme through his network of assisted living and skilled nursing facilities.  Esformes bribed physicians to admit patients, then provided them with inadequate, inappropriate, or unnecessary services.  To ensure his facilities maintained state licenses, he bribed Florida state regulators.  DOJ; USAO SD FL

September 12, 2019

New Jersey doctor Joseph DeCorso pleaded guilty to fraudulently prescribing orthotic braces over the phone for two telemedicine companies, resulting in a $13 million loss to Medicare. Dr. DeCorso admitted that the telemedicine companies preyed on elderly and disabled Medicare beneficiaries, on behalf of whom he submitted orders for medically unnecessary braces. He prescribed these braces without ever speaking to or consulting with these patients. The case was investigated by the FBI and the U.S. Department of Health and Human Services Office of the Inspector General. DOJ
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