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:
April 12, 2022
Providence Health & Services Washington has agreed to pay $22.7 million to settle allegations of submitting false claims to Medicare, Medicaid, and TRICARE. According to an unnamed whistleblower, who will receive a $4.2 million relator’s share, the hospital allegedly gave their neurosurgeons volume-based financial incentives to perform complex surgeries, thereby incentivizing two neurosurgeons to perform an excessive number of complex surgeries on inappropriate candidates without regard to medical necessity or patient safety, and ultimately causing an excessive level of complications. USAO EDWAApril 12, 2022
Physician Partners of America LLC (PPOA), its founder Rodolfo Gari, and its former chief medical officer Dr. Abraham Rivera, have agreed to pay $24.5 million to settle allegations of violating the Stark Law, False Claims Act, and Financial Institutions Reform, Recovery and Enforcement Act (FIRREA). The settlement resolved claims by whistleblowers Donald Haight, Dawn Baker, Dr. Harold Cho, Dr. Venus Dookwah-Roberts, and Dr. Michael Lupi, all currently or formerly employed with PPOA. According to the whistleblowers and the government, PPOA allegedly billed Medicare and Medicaid for medically unnecessary testing, paid illegal kickbacks to its physician employees, and made false statements on a loan from the Paycheck Protection Program. USAO MDFLMarch 31, 2022
Clinical laboratory Radeas LLC has agreed to pay $11.6 million to resolve claims that it submitted false claims to Medicare for medically-unnecessary urine drug tests. As part of the settlement agreement, Radeas admitted that it regularly performed and billed Medicare for essentially simultaneous presumptive qualitative drug testing and confirmatory quantitative drug testing. Without physician review of a presumptive test result, the separate, simultaneous confirmatory test was often not necessary. Radeas also admitted that it paid third-party sales organizations based on the volume of UDT referrals in violation of the Anti-Kickback Statute. USAO MAMarch 24, 2022
A New York woman who defrauded the state out of millions of dollars has been sentenced to 3 to 9 years in prison and ordered to pay more than $4 million in restitution. According to the Attorney General’s Office, Leslie Montgomery lured low-income New Yorkers to Health Living Community Center under the guise of helping them find housing, then used their information to submit false claims to a Medicaid-funded managed care organization. The claims for custom-molded back braces were medically unnecessary and not requested by or provided to the intended recipients. Montgomery then hid the illegal proceeds through multiple shell companies, including LCM Livery P/U, Inc. NY AGMarch 21, 2022
Jonathan and Daniel Markovich, two brothers who operate addiction treatment facilities in Florida, have been sentenced to over 15 years and 8 years in prison respectively after being convicted of running a $112 million fraud scheme. Through patient recruiters, the defendants paid illegal kickbacks to patients in the form of airline tickets, cash payments, and illegal drugs to entice them to visit their inpatient detox and residential facility, Second Chance Detox LLC d/b/a Compass Detox, as well as their outpatient treatment program, WAR Network LLC. The defendants then billed for therapy sessions that were not regularly provided to or attended by patients, and urine drug tests that were not medically necessary. DOJMarch 9, 2022
Sixteen defendants from Michigan and Ohio have been sentenced to prison for their roles in a massive $250 million healthcare fraud scheme that involved subjecting opioid-addicted patients to medically unnecessary back injections in exchange for more opioids. The injections were selected because they were reimbursed highly by government payors, but were often painful or led to adverse conditions, such as open holes in the back. DOJMarch 8, 2022
Eugene Sisco, III of Kentucky, the owner and operator of several medication assisted treatment (MAT) clinics for opioid addiction, has been sentenced to over 10 years in prison and ordered to pay $5.7 million in restitution, after being convicted of healthcare fraud. Sisco was found to have tricked Medicaid patients into paying hundreds of dollars in cash each month for MAT services which he later billed and was reimbursed by Medicaid for. Sisco’s laboratory, Toxperts, LLC, was also found to have billed Medicare for medically unnecessary urine drug tests, causing a loss of over $2 million to CMS. USAO EDKYCatch of the Week: Texas Hospice CEO Gets 13 Year Sentence in $60 Million Fraud Scheme
Posted 01/28/22
Top Ten Financial and Healthcare Fraud Prison Sentences of 2021
Posted 01/28/22
