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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 24 of 48

October 9, 2018

A Florida-based pharmacy owner has plead guilty to defrauding Medicare of $8.4 million. In order to generate income for his pharmacy, Valles Pharmacy Discount, Antonio Perez Jr. allegedly paid kickbacks to Medicare beneficiaries and submitted claims on their behalf for medically unnecessary prescriptions that were not purchased by the pharmacy or provided to the beneficiaries. DOJ

Tagged in: Healthcare Fraud, Lack of Medical Necessity, Pharma Fraud,

October 9, 2018

The former CFO and COO of Houston-area Atrium Medical Center and Pristine Healthcare, Starsky Bomer, has been convicted for his role in a $16 million Medicare kickback scheme.  Bomer and others paid illegal kickbacks to group home owners and patient recruiters in exchange for the referral of Medicare patients for outpatient mental health treatment through the hospitals' partial hospitalization program (PHP).  While the hospitals billed Medicare $16 million for these patients, the evidence at trial demonstrated that Bomer knew that PHP services were not necessary for most of the patients, and that the patients were not, in fact, provided with such services.   DOJ

Tagged in: Anti-Kickback and Stark, Hospital Fraud, Lack of Medical Necessity, Medical Billing Fraud,

October 4, 2018

Mercy Ainabe of Houston, Texas, was sentenced to nine years in prison for her role in a $3.6 million home healthcare Medicare fraud scheme.  Ainabe served as a patient recruiter, selling patient information to home healthcare companies, including Texas Tender Care, which then submitted claims to Medicare for home health services that were not medically necessary, were not provided, or both. USAO SDTX

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

September 27, 2018

Millicent Traylor, M.D., of Detroit, Michigan was sentenced to over 11 years in prison today for her part in a health care scheme against Medicare from 2011 to 2016. Traylor and her co-conspirators defrauded Medicare of an estimated $8.9 million during that period. They submitted fraudulent claims for home health care services and other services which were not provided or not medically necessary. At times, the physician services which were provided were provided by Dr. Traylor, though she was unlicensed during that period. Furthermore, evidence presented during the four-day trial showed that Traylor forged the signature of licensed physicians on prescriptions for opioid medications, oxycodone for instance, as a way to encourage patient participation in the scheme. Traylor’s three co-conspirators will also serve time in prison.  DOJ  

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

September 24, 2018

The owner and operator of several Superdrugs pharmacies in Queens, New York, was charged with submitting false claims to Medicare Part D and Medicaid for prescription drugs that were not dispensed, were not prescribed as claimed, or not medically necessary.  The pharmacies allegedly received $7.9 million from Medicare and Medicaid based on the fraudulent claims.  DOJ

Tagged in: Lack of Medical Necessity, Medical Billing Fraud, Part D, Pharma Fraud,

September 19, 2018

A physician and two clinic operators were convicted after trial for charges arising from a $17 million Medicare fraud scheme.  The doctor, John Ramirez, provided medical orders falsely certifying the need for home-health services, which the other defendants then sold to to home-health agencies in the Houston, Texas area.  These agencies then used the false and fraudulent paperwork signed by Ramirez to submit false claims to Medicare for medical services that were not medically necessary or not provided.  DOJ

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

September 4, 2018

Houston psychiatrist Riyaz Mazcuri was sentenced to 12.5 years in prison following his conviction at trial for defrauding Medicare and Medicaid through the submission of $155 million in false and fraudulent claims for "partial hospitalization program" services, a form of intensive outpatient treatment for patients with mental illness.  Mazcuri falsified records to make it appear as if patients admitted to the PHPs qualified for, required, and actually received the intensive psychiatric services. DOJ

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

August 28, 2018

Dermatology Healthcare will pay $4 Million to settle allegations of healthcare fraud which violate the False Claims Act. Dermatology Healthcare submitted false claims in order to be paid millions in Medicare and Medicaid reimbursements for treatment of non-melanoma skin cancer during which superficial radiation therapy is administered. It is alleged that the superficial radiation therapy was not properly supervised during treatment and that other procedures in relation to superficial radiation therapy were up-coded. It is further alleged that the radiation simulations were overly used. This settlement is the conclusion of a lawsuit filed by dermatologist Theodore A. Schiff, M.D., under the qui tam provisions of the False Claims Act in the United States District Court for the Middle District of Florida. DOJ

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

August 20, 2018

The owner of an ambulance company has been convicted of defrauding Medicare by submitting claims for over $3 million in unprovided or unnecessary transport services. Anthony Nwosah of Tonieann EMS and Rosenberg EMS also admitted to falsifying and instructing others to falsify transport records, as well as submitting some under the name of an EMT who didn’t even work for him. He received $1,094,260 before the fraud was uncovered, and at his sentencing in November, he stands to receive a $250,000 fine and ten year sentence. USAO SDTX

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

August 6, 2018

Grenada Lake Medical Center will pay $1.1M to settle allegations that it violated the FCA by submitting claims for medically unnecessary psychotherapy services to the Medicare program. The alleged fraud lasted over eight years and was brought to light by a whistleblower, a former programs manager at the company, who will receive an award of $195k. USAO Eastern District of Arkansas

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

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