Lack of Medical Necessity

February 23, 2018

Maine-based North East Mobile Health Services agreed to pay $825,000 to settle claims it violated the False Claims Act by providing medically unnecessary ambulance transportation. Maine Medical Center also agreed to pay $600,000 pursuant to a separate civil settlement. According to the government, North East improperly billed Medicare for ambulance transports of patients it falsely claimed were either “bed-confined” or for whom such transport was otherwise medically necessary. The government further alleged that MMC personnel provided North East with statements containing incomplete or inaccurate information about the medical necessity of transporting patients by ambulance, which North East thereafter used to bill Medicare. DOJ (ME)

February 22, 2018

Samuel Konell was sentenced to 60 months in prison and pay roughly $10 million for his role in a $63 million health care fraud scheme involving now-defunct Greater Miami Behavioral Healthcare Center Inc. which purported to provide partial hospitalization program (PHP) services to individuals suffering from mental illness. Konell admitted he received kickbacks and/or bribes in return for referring Medicare beneficiaries from the Miami-Dade state court system to Greater Miami to serve as patients. He admitted he coordinated with criminal defendants in the state court system to obtain court orders for mental health treatment in lieu of incarceration so that he could refer those individuals to Greater Miami to serve as patients in return for kickbacks and/or bribes. Konell further admitted that he did so knowing that certain of those individuals were not mentally ill or otherwise did not meet the criteria for PHP treatment. DOJ

February 13, 2018

Detroit-area doctor Mahmoud Rahim was sentenced to 72 months in prison and ordered to forfeit roughly $1.7 million for his role in a $10.4 million conspiracy to defraud the Medicare program. According to the evidence presented at trial, Rahim accepted kickbacks in exchange for referring Medicare patients for electromyogram tests, some of which were unnecessary, and physical therapy performed by unlicensed individuals. DOJ

February 8, 2018

Privately owned for-profit hospice company Horizons Hospice, LLC and its owner agreed to pay roughly $1.2 million to settle claims they violated the False Claims Act for billing Medicare and Medicaid for hospice services for patients who were ineligible for hospice. The allegations originated in two whistleblower lawsuits filed under the qui tam provisions of the False Claims Act.  DOJ (WDPA)

January 30, 2018

Tampa’s largest ambulance providers AmeriCare Ambulance Service, Inc. and its sister company AmeriCare ALS, Inc. agreed to pay roughly $5.5 million to settle claims they violated the False Claims Act by billing Medicare for medically unnecessary ambulance transportation services. The allegations originated in a whistleblower lawsuit filed under the qui tam provisions of the False Claims Act by former AmeriCare employee Ernest Sharp. He will receive a whistleblower award of roughly $1.15 million from the proceeds of the government’s recovery. DOJ (MDFL)

January 24, 2018

Tennessee chiropractor Matthew Anderson agreed to pay $1.45 million to resolve allegations he violated the False Claims Act. Specifically, the government alleged that Anderson and his management company, PMC LLC, caused pharmacies to submit requests for Medicare and TennCare payments for pain killers dispensed based upon prescriptions written at the Cookeville Center for Pain Management, one of the pain clinics Anderson managed, which had no legitimate medical purpose. The government further alleged that Anderson caused four pain clinics he managed to bill Medicare for upcoded claims for office visits that were not reimbursable at the levels sought. The allegations originated in a whistleblower lawsuit filed by a former office manager for the Cookeville Center for Pain Management under the qui tam provisions of the False Claims Act. The whistleblower will receive a whistleblower award of $246,500 from the proceeds of the government's recovery. DOJ

January 23, 2018

California medical device company DJO Global Inc. agreed to pay $7.62 million to resolve allegations that its Minnesota subsidiary Empi Inc. submitted false claims to TRICARE for excessive, unnecessary transcutaneous electrical nerve stimulation electrodes that TRICARE beneficiaries did not need or use. TENS is a therapy that uses low-voltage electrical current for pain relief. DOJ