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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:

Page 21 of 48

March 21, 2019

Nonprofit healthcare organization MedStar Health Inc. has agreed to pay $35 million to the United States to settle two qui tam lawsuits alleging violations of the False Claims Act at two of its hospitals in Baltimore. According to the first complaint, filed by three cardiac surgeons, MedStar paid illegal remuneration to MidAtlantic Cardiovascular Associates (MACVA) to induce referrals of Medicare patients. The second complaint, filed by former patients, alleged that while employed by MedStar, former MACVA employee Dr. John Wang engaged in a pattern of performing and billing for medically unnecessary cardiac stent procedures. DOJ

Tagged in: Anti-Kickback and Stark, Healthcare Fraud, Lack of Medical Necessity, Medicare, Provider Fraud, Whistleblower Case, Whistleblower Rewards,

March 7, 2019

A Connecticut-based durable medical equipment supplier, Med Tech, and its owner, Thomas Macre, Sr., have agreed to pay more than $467,000 to resolve allegations of violating the federal and state False Claims Acts. The alleged misconduct involved billing Medicaid for unprovided and medically unnecessary back braces and electrical stimulation units. USAO CT

Tagged in: FCA Federal, FCA State, Healthcare Fraud, Lack of Medical Necessity, Medicaid,

March 6, 2019

A Texas woman has been sentenced to 30 years in prison and ordered to pay more than $15 million for her role in a $50 million scheme involving healthcare fraud and money laundering. Daniela Gozes-Wagner was accused of running 28 fake medical testing facilities from 2009, and billing Medicare and Medicaid for tests that were not performed or medically necessary. As part of the scheme, she employed personnel to answer phones and prevent inspectors from entering "testing facilities" that were virtually empty. USAO SDTX

Tagged in: Healthcare Fraud, Lack of Medical Necessity, Medicaid, Medicare, Misrepresentations,

February 27, 2019

The owner and operator of a drug marketing company has pleaded guilty for his role in a $200 million scheme to defraud TRICARE in one of the largest healthcare fraud cases said to come out of Mississippi. Between 2012 and 2016, Howard Randall Thomley of Advantage Marketing Professionals allegedly recruited TRICARE beneficiaries to accept millions of dollars of medically unnecessary compounded medications by paying them a percentage of prescription revenues. The prescriptions forms — signed by medical professionals who never saw the recruited beneficiaries — were then filled by a compounding pharmacy, Advantage Pharmacy, who paid Thomley a portion of the reimbursements. For his role in the scheme, Thomley now faces a maximum sentence of 10 years in federal prison at his sentencing in July. USAO SDMS

Tagged in: Compounding Pharmacy Fraud, Healthcare Fraud, Lack of Medical Necessity, Other Government Health Programs,

February 20, 2019

Hope Thomley of Hattiesburg, Mississippi, pleaded guilty for her role in a compounding pharmacy kickback scheme.  Thomley was the owner and operator of acompany that marketed for Advantage Pharmacy in Hattiesburg, and received 50% of Advantage's reimbursements.  Thomley admitted that she knew Advantage submitted false claims for payment to federal healthcare programs for medications that had not been prescribed by a doctor or were not medically necessary.  Between 2012 and 2016, health care benefit programs, including TRICARE, reimbursed Advantage Pharmacy and other pharmacies involved in the scheme at least $200 million. DOJ

Tagged in: Anti-Kickback and Stark, Compounding Pharmacy Fraud, Lack of Medical Necessity, Other Government Health Programs, Pharma Fraud,

February 19, 2019

Xerox Corporation will pay $236 million to the State of Texas to resolve claims that the company and its subsidiary Conduent, which provided services to the Texas Medicaid program, improperly approved requests for orthodontic procedures without ensuring that the procedures met Medicaid program requirements.  As a result, the state paid for orthodontic work that was unnecessary or did not meet program requirements.  Texas

Tagged in: Healthcare Fraud, Lack of Medical Necessity, Medicaid, Medical Billing Fraud,

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

Tagged in: Healthcare Fraud, Improper Medical Personnel, Lack of Medical Necessity, Medicaid, Medical Billing Fraud, Upcoding,

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

Tagged in: Compounding Pharmacy Fraud, Criminal Proceedings, Healthcare Fraud, Lack of Medical Necessity, Other Government Health Programs,

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

Tagged in: Compounding Pharmacy Fraud, FCA Federal, Lack of Medical Necessity, Pharma Fraud, Whistleblower Case,

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

Tagged in: Certifications, Criminal Proceedings, Healthcare Fraud, Improper Medical Personnel, Lack of Medical Necessity, Medicare,

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