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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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Charges Filed in Shameful COVID-19 and Genetic-Cancer-Screening Test Scam

Posted  04/3/20
doctor-mask
Erik Santos of Braselton, Georgia had run a fraudulent genetic cancer-screening-test scheme for months, then spotted an opportunity capitalize on fear surrounding COVID-19.  According to the criminal complaint, Santos targeted elderly persons to determine if they met certain eligibility requirements for testing under government health-care programs.  He passed the information along to co-conspirator testing...

Tracking Medicaid Fraud: HHS OIG Releases MFCU Annual Report

Posted  04/2/20
Human Health Services Office of Inspector General Logo
The HHS OIG recently released the Medicaid Fraud Control Units (MFCUs) Fiscal Year 2019 Annual Report, providing a consolidated accounting of the program’s success. MFCUs investigate and prosecute Medicaid fraud and patient abuse or neglect. MFCUs receive referrals from other agencies, the public, or via data mining with OIG approval. The referral is reviewed, an investigation is conducted, and the decision is...

February 28, 2020

Nursing home chain Diversicare Health Services, Inc. has agreed to pay $9.5 million to resolve whistleblower-brought allegations of submitting claims to Medicare and Medicaid for medically unnecessary rehabilitation therapy services.  According to separate qui tam complaints by former employees, Mary Haggard and Bryant Fitzmorris, between 2010 to 2015, Diversicare unnecessarily placed beneficiaries in the highest category of reimbursement in order to receive higher payouts, and submitted forged pre-admission evaluation certifications to Medicaid.  As part of the settlement, Diversicare has entered into a Corporate Integrity Agreement for five years, Haggard will receive approximately $1.4 million, and Fitzmorris will receive approximately $145,450.  DOJ; USAO MDTN

February 19, 2020

Guardian Elder Care Holdings, Inc. has agreed to pay $15.5 million to settle claims of defrauding Medicare and Medicaid.  In a qui tam suit filed in 2015, whistleblowers Philippa Krauss and Julie White alleged that from 2011 to 2017, the Pennsylvania-based nursing home chain pressured its therapists to provide medically unnecessary rehabilitation to patients suffering from dementia or dying in hospice care in order to boost its profits.  During the subsequent government investigation, Guardian Elder Care self-disclosed that it had also billed federal healthcare programs for services performed by two excluded individuals.  As part of the settlement, Guardian Elder Care has entered into a chain-wide Corporate Integrity Agreement with the Department of Health and Human Services, and Krauss and White will split a $2.8 million relator's share.  USAO EDPA; USAO WDPA

February 11, 2020

Tenet Healthcare Corporation and its affiliated hospital, Desert Regional Medical Center, have agreed to pay $1.4 million to settle allegations that they knowingly charged Medicare for medically unnecessary cardiac monitors, in violation of the False Claims Act.  According to former DRMC employee, Michael Grace, the devices were implanted between 2014 to 2017, exposing beneficiaries to unnecessary risk and causing the government unnecessary expenses.  For exposing the fraud, Grace will receive a $240,789 share of the recovery.  DOJ

February 3, 2020

Senthil Kumar Ramamurthy of Texas has been sentenced to 10 years in prison for participating in two fraud schemes that amounted to $9.6 million in losses by Medicare and TRICARE.  In the first scheme, which ran for 10 months in 2014, Ramamurthy and his co-conspirators were paid millions of dollars by compounding pharmacies to get TRICARE beneficiaries to sign up for medically unnecessary compounded prescription drugs.  To get beneficiaries to sign up, defendants had falsely represented that the drugs would be free, when in fact co-payments were required.  In the second scheme, which ran from 2015 onward, Ramamurthy and his co-conspirators paid doctors to refer Medicare beneficiaries—without first examining them—for needless genetic cancer screening tests.  Many of Ramamurthy's co-conspirators have plead guilty and face sentencing later this month.  USAO SDFL

January 29, 2020

A Florida-based physician, Erik Schabert, and his ex-wife, Mika Harris, have been sentenced to 3.5 years and 3 months in prison, and ordered to pay almost $4.5 million in restitution to Blue Cross Blue Shield for attempting to defraud the insurer and the Medicare program of more than $8 million.  Between 2013 and 2016, the two owners and operators of Reliant Family Practice falsely diagnosed actinic keratosis and rosacea in order to make fraudulent claims for chemical peels and dermabrasions.  Along with prison time and restitution, the two have forfeited their private residence, commercial property, and over $260,000 in an annuity account, to the federal government.  USAO NDFL

January 16, 2020

A former pharmaceutical sales representative in Texas has been sentenced to 2.5 years in prison and ordered to pay $1,746,222 in restitution for participating in a healthcare bribery scheme from 2013 to 2014.  In return for receiving commissions from pharmacies and paying them to medical providers, Holly Blakely had submitted fraudulent prescriptions to two different compounding pharmacies on behalf of unsuspecting individuals, causing approximately $8.8 million in losses to private and government healthcare providers.  USAO WDTX

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
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