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:
July 26, 2018
New York announced guilty pleas by transportation company 716 Transportation, Inc., its president, and one of its drivers, in connection with a $1.2 million Medicaid fraud scheme. The company and its president admitted to billing Medicaid for transportation services that were either never provided or that violated Medicaid rules and regulations. NY AG10th Circuit Finds that Doctor’s Judgment is Not Automatically Reasonable and Necessary
Posted 07/20/18
By Poppy Alexander
Top-level heart surgeons work in a rarified world, where few may question their medical judgment. Yet that judgment is not infallible-and its presence is not in itself a protection against False Claims Act liability. The Tenth Circuit recently held as much in United States ex rel. Polukoff v. St. Mark’s Hospital et al., finding that a doctor may be exercising medical judgment while still...
July 18, 2018
Two consulting companies and nine nursing homes will pay $10M to resolve allegations that they submitted claims for medically unnecessary rehabilitation services to Medicare. Medicare reimburses nursing homes based on Resource Utilization Group (RUG) levels, which are supposed to determine the amount of skilled therapy required by a patient. The government alleges that the nursing homes, as advised by the consulting companies, encouraged medically unreasonable and unnecessary therapy to inflate RUG levels. The case was filed by three whistleblower, who will receive a total award of $2M. DOJJuly 13, 2018
Orthopedic specialists in Oklahoma have agreed to pay $670,000 to settle allegations in a False Claims Act qui tam that they falsely billed Medicare, Medicaid, and Tricare for unnecessary ultrasonic guidance procedures and for services that were not performed. The settlement resolved two claims in the whistleblower action, brought by a former employee, in which the government had intervened prior to settlement; other claims continue to be litigated. USAO WDOKJuly 10, 2018
The New Mexico U.S. Attorney’s Office announced the sentencing of a cardiologist to 51 months in prison for healthcare fraud and obstruction of justice. Roy Heilbron had been indicted for regularly performing unnecessary diagnostic tests on his patients and falsifying medical records to cover the fraudulent billing; he also had billed for procedures that were never performed. USAO NMJune 22, 2018
Dr. Kelly Robinett and Kingsley Nwanguma were each convicted of multiple counts of conspiracy to commit health care fraud and health care fraud. Joy Ogwuegbu was also convicted of four counts of health care fraud. The conviction were related to a scheme by the three to overbill Medicare for medically unnecessary home health services that in many cases were not provided. The scheme billed Medicare $11.3 million for home health care services pursuant to certifications signed by Robinett and approximately $1 million related to medically unnecessary home health services. Sentencing has not yet been scheduled. DOJJune 21, 2018
Livingston Regional Hospital, a healthcare provider outside of Nashville, has paid $784K to settle FCA allegations that it improperly billed Medicare Part A for inpatient psychiatric care that was not medically necessary. The allegations were first brought forward by two whistleblowers who will receive a $156K reward. USAO Middle District of TennesseeCatch of the Week -- Healogics
Posted 06/22/18
This week's Department of Justice "Catch of the Week" goes to Healogics, Inc. On Wednesday, the Florida-based operator of hundreds of wound care centers agreed to pay up to $22.5 million to settle claims it violated the False Claims Act by billing Medicare for medically unnecessary and unreasonable hyperbaric oxygen therapy. See DOJ Press Release.
Hyperbaric therapy involves breathing oxygen inside a pressurized...