Lack of Medical Necessity Archives - Page 22 of 48

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

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

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

Tagged in: FCA Federal, FCA State, Lack of Medical Necessity, Medicaid, Pharma Fraud, Whistleblower Case, Whistleblower Rewards,

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

Tagged in: Ambulance, Lack of Medical Necessity,

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

Posted 12/21/18

Younger person resting hand on hand of seated elderly woman with cane

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...

Tagged in: Catch of the Week, FCA Federal, Home Health and Hospice, Lack of Medical Necessity, Whistleblower Case,

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

Tagged in: Anti-Kickback and Stark, FCA Federal, Healthcare Fraud, Lack of Medical Necessity, Provider Fraud,

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 $446,000. USAO MDFL

Tagged in: FCA Federal, Healthcare Fraud, Improper Medical Personnel, Lack of Medical Necessity, Medical Billing Fraud, Provider Fraud, Upcoding, Whistleblower Case, Whistleblower Rewards,

December 18, 2018

After submitting more than $3.5 million in false Medicare claims for home health services, John Dubor of Sugar Land, Texas, has been sentenced to nine years in prison and ordered to pay $3.5 million in restitution. Through his company, Care Committers Health Services, Dubor paid marketers and group home owners for Medicare beneficiary information, then falsely billed Medicare and Medicaid for home health services for which the beneficiaries did not qualify, did not receive, or both. Dubor himself would falsify patient assessment forms to make patients appear sicker, entitling him to higher reimbursement rates, and instructed his employees to falsify certifications and forge physician signatures. USAO SDTX

Tagged in: Criminal Proceedings, Healthcare Fraud, Home Health and Hospice, Lack of Medical Necessity, Medical Billing Fraud,

December 14, 2018

Crossroads Hospice of Kansas has agreed to pay $300,000 for violating the Kansas False Claims Act. Under that law, once a healthcare provider is alerted to charges improperly submitted to the state's Medicaid program, it is obligated to refund the reimbursement in a timely manner or risk prosecution. In the case of Crossroads, the provider had failed to refund money paid on behalf of improperly certified beneficiaries. KS AG

Tagged in: FCA State, Home Health and Hospice, Lack of Medical Necessity, Medicaid,

December 13, 2018

Hospice care provider SouthernCare, Inc. has agreed to pay $5,863,426 for submitting fraudulent claims to Medicare between 2009 to 2014. Under Medicare's eligibility rules, in order for hospice care to be reimbursed, a patient must have a life expectancy of six months or less as certified by a physician, and terminal illnesses must be documented with appropriate records. However, according to qui tam complaints by former employees Dawn Hamrock and Patricia Beegle, SouthernCare billed Medicare for care provided to patients who were not Medicare eligible or who had no proof of Medicare eligibility. As part of the settlement, Hamrock and Beegle will share a $1.1 million whistleblower reward. USAO EDPA

Tagged in: FCA Federal, Healthcare Fraud, Lack of Medical Necessity, Medicare, Whistleblower Case, Whistleblower Rewards,

December 3, 2018

Feng Qin, M.D., a vascular surgeon who in 2015 settled claims that he performed medically-unnecessary vascular surgeries, has again been charged with such unlawful practices. As reported by an unidentified whistleblower who brought a case under the False Claims Act, Qin routinely scheduled patients for surgeries months in advance, regardless of whether there was a justifiable clinical reason for the surgery. At times, Qin would alter medical records. Qin would then bill Medicare for these procedures, despite his knowledge that procedures on patients that are not medically reasonable and necessary are not covered by Medicare. USAO SDNY

Tagged in: FCA Federal, Lack of Medical Necessity, Provider Fraud, Whistleblower Case,

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