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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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January 10, 2020

The owner of two Philadelphia-based testing laboratories has pleaded guilty and agreed to pay more than $77 million in restitution for participating in an illegal kickback scheme.  At his plea hearing, Ravitej Reddy admitted that his laboratories, Personalized Genetics, LLC and Med Health Services Management, LP, participated in a fraudulent scheme that took advantage of the labs' location in a high reimbursement area for Medicare cancer and pharmacogenetic testing the labs actually sent for testing to a laboratory that was located outside of the lucrative coverage area, because the labs lacked equipment to perform the tests themselves.  To secure the lab orders, Reddy admitted paying kickbacks to co-conspirators, including marketers that solicited specimens from Medicare beneficiaries, and a telemedicine practice that improperly authorized the tests without regard to medical necessity.  In addition to the restitution order, Reddy faces a maximum of 25 years in prison at his sentencing in February.  USAO WDPA

December 17, 2019

Miracle Home Care, Inc. and its owner, Shashicka Tyre-Hill, have together been ordered to pay more than $10 million following judgment in an action under the False Claims Act finding that defendants defrauded Georgia’s Medicaid program.  In a civil complaint filed in July 2018, the federal government and State of Georgia alleged that Miracle Home Care submitted thousands of fraudulent reimbursement claims for medically unnecessary transportation and health services.  USAO SDGA

December 10, 2019

Dr. Paul J. Mathieu and occupational therapist Lina Zhitnik have been sentenced to, respectively, 4 years and 1.2 years in prison, for their roles in a $30 million scheme to defraud Medicare and New York's Medicaid program.  Mathieu falsely posed as the owner of three medical clinics, which were actually owned by Aleksandr Burman, and Mathieu and Zhitnik falsely claimed to have treated thousands of patients at those clinics.  Over six years, Mathieu prepared or assisted in the preparation of false and fraudulent medical charts, issued referrals for expensive and unnecessary additional testing by providers also participating in the scheme, and wrote prescriptions for unnecessary medical supplies that were filled by a company also owned by Burman.  Another doctor participating in Burman's scheme, Ewald J. Antoine, was previously sentenced.  USAO SDNY

December 5, 2019

Maryland-based internist Noman Thanwy, M.D. has paid over $176,000 to settle allegations of submitting false claims to Medicare for medically unnecessary autonomic nervous function and vestibular function tests.  Although the tests are typically performed only once per beneficiary to confirm diagnoses of relatively uncommon disorders, Dr. Thanwy, who lacked the necessary training and equipment to perform the tests, was allegedly using them to monitor patient symptoms.  USAO MD

November 8, 2019

In the eleventh settlement involving the multi-state OK Compounding Pharmacy fraud scheme, podiatrist Jonathan Moore of Kentucky has agreed to pay $65,404 for the role he played in defrauding federal healthcare programs.  In exchange for illegal kickbacks disguised as “medical director fees,” Dr. Moore allegedly prescribed medically unnecessary compounded pain creams to patients, many of whom were insured by Medicare and TRICARE.  USAO NDOK

October 28, 2019

Sanford Health, Sanford Medical Center, and Sanford Clinic have agreed to pay $20.25 million and enter into a Corporate Integrity Agreement in order to resolve alleged violations of the Anti-Kickback Statute and False Claims Act.  Despite warnings by several physicians that a top neurosurgeon was illegally profiting off his use of implantable medical devices as well as performing medically unnecessary surgeries involving the devices, Sanford did nothing to stop the offender, allowing Medicare and Medicaid to continue being defrauded.  The allegations were raised by Sanford surgeons Drs. Carl Dustin Bechtold and Bryan Wellman, who will share in a $3.4 million cut of the settlement proceeds.  DOJ; USAO SD

CATCH OF THE WEEK – Osteo Relief Institutes, Pedaling Dubious Treatment for Arthritis, Tagged for Charging Medicare for Medically Unnecessary Services

Posted  10/25/19
x-ray of a knee
On October 18, 2019, the Department of Justice announced a settlement with arthritis treatment provider Osteo Relief Institutes and seven of its locations in Phoenix, Arizona; San Diego, California; Lexington, Kentucky; Wall Township, New Jersey; Dallas, Texas; San Antonio, Texas; and, Colorado Springs, Colorado.  According to the DOJ press release, the ORI entities, together with their principals, will collectively...

October 18, 2019

Following a government analysis of Medicare claims data and a whistleblower's qui tam lawsuit, seven former Osteo Relief Institutes and their owners have agreed to pay more than $7.1 million to settle claims of defrauding Medicare.  The alleged fraud involved clinics in Arizona, California, Kentucky, New Jersey, and Texas billing Medicare for medically unnecessary treatments for osteoarthritis, including viscosupplementation injections and knee braces.  The whistleblower involved will receive $857,550.  DOJ

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
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