Lack of Medical Necessity

November 30, 2017

Florida-based Express Plus Pharmacy, LLC and its owner Antonio Primo agreed to pay $170,000 to resolve allegations they violated the False Claims Act by submitting fraudulent claims to Tricare for compounded medications such as pain creams that were not reimbursable because they were not issued pursuant to valid physician-patient relationships, were issued after brief phone calls with patients that violated applicable law on telemedicine, were medically unnecessary, and/or were tainted by kickbacks to marketers.  DOJ (SDFL)

November 28, 2017

California-based Cardiovascular Consultants Heart Center and its shareholder physicians -- Dr. Kevin Boran, Dr. Michael Gen, Dr. Rohit Sundrani, Dr. Donald Gregory, and Dr. William Hanks -- agreed to pay $1.2 million to settle allegations of violating the False Claims Act by billing Medicare and Medicaid for medically unnecessary cardiovascular diagnostic procedures.  According to the government, company physicians automatically scheduled patients for nuclear stress tests on an annual basis without seeing the patients beforehand to confirm the procedure was necessary.  These test are expensive and expose patients to a significant amount of radiation as well as to the risk of invasive procedures based on false positive results.  This risk is only justified if the nuclear stress test is medically necessary.  DOJ (EDCA)

October 30, 2017

Ohio-based Chemed Corporation and various wholly-owned subsidiaries, including Vitas Hospice Services LLC and Vitas Healthcare Corporation, agreed to pay $75 million to resolve charges they violated the False Claims Act by submitting claims for hospice services to Medicare for patients not terminally ill.  Vitas is the largest for-profit hospice chain in the United States and was acquired by Chemed in 2004.  The government alleged the defendants rewarded employees with bonuses for the number of patients receiving hospice services, without regard to whether they were actually terminally ill and whether they would have benefited from continuing curative care.  The government further alleged that Vitas submitted false claims to Medicare for continuous home care services that were not necessary, not actually provided, or not performed in accordance with Medicare requirements.  The allegations originated in several whistleblower lawsuits filed under the qui tam provisions of the False Claims Act.  The whistleblowers will receive a portion of the proceeds of the government's recovery.  DOJ

October 24, 2017

A federal judge awarded the government roughly $2 million in a verdict against Maryland-based home health care company Dynamic Visions, Inc. for violating the False Claims Act because its employees repeatedly and routinely falsified records to obtain funds from Medicaid.  Specifically, a government investigation found many of the company's patient files did not contain physician authorizations, called “plans of care,” as required under applicable regulations; contained plans of care that were not signed by physicians or other qualified health care workers; or contained forged signatures in order to cover up the lack of a physician’s authorization. DOJ (DDC)

October 3, 2017

Michigan physician Abdul Haq pleaded guilty to conspiracy to commit health care fraud for his role in an approximately $19 million Medicare fraud scheme involving three Detroit area providers.  Haq admitted he conspired with the owner of the Tri-County Network and others to prescribe medically unnecessary controlled substances, including Oxycodone, Hydrocodone and Opana, to Medicare beneficiaries, many of whom were addicted to narcotics. DOJ

September 20, 2017

Miami physician Roberto A. Fernandez was sentenced to 97 months in prison and to pay $4.8 million in restitution for his role in a $4.8 million health care fraud scheme that involved the submission of false and fraudulent claims to Medicare and the illegal prescribing of controlled substances, including oxycodone and hydrocodone. DOJ

September 20, 2017

New Jersey-based durable medical equipment supplier R&V Medical Supplies LLC and its former owner Victor Saul agreed to pay $220,000 to settle charges of violating the False Claims Act by engaging in a scheme to defraud Medicare by billing for equipment not properly authorized by a physician or not actually provided. DOJ (EDPA)

September 8, 2017

Galena Biopharma Inc. agreed to pay more than $7.55 million to resolve allegations it violated the False Claims Act by paying kickbacks to doctors to induce them to prescribe its fentanyl-based drug Abstral.  These included providing more than 85 free meals to doctors and staff from a single, high-prescribing practice; paying doctors thousands of dollars to attend an “advisory board,” and paying roughly $92,000 to a physician-owned pharmacy under a performance-based rebate agreement.  Two of the doctors who received remuneration from Galena were convicted and later sentenced to prison.  The allegations originated in a whistleblower lawsuit filed under the qui tam provisions of the False Claims Act by Lynne Dougherty.  She will receive a whistleblower award of more than $1.2 million from the proceeds of the government's recovery. DOJ

August 3, 2017

The Medical Center of Central Georgia, Inc. (d/b/a The Medical Center, Navicent Health) agreed to pay roughly $2.6 million to resolve allegations it violated the False Claims Act by submitting bills for ambulance transports that were either inflated or medically unnecessary.  The allegations originated in a whistleblower lawsuit filed under the qui tam provisions of the False Claims Act by former Navicent paramedic Andre Valentine.  He will receive a yet-to-be-determined whistleblower award from the proceeds of the government's recovery.  DOJ (MDGA)