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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 32 of 48

June 22, 2017

Dr. James M. Crumb, a physical medicine and rehabilitative specialist currently practicing in Alabama as Mobility Metabolism and Wellness, P.C.,and Coastal Neurological Institute, P.C., a local neurosurgeon physician group, agreed collectively to pay $1.4 million to resolve allegations they violated the False Claims Act by billing federal health care programs for medically unreasonable and unnecessary ultrasound guidance used with routine lab blood draws, and with Botox and trigger point injections. As a result of this billing scheme, the defendants sometimes billed 15 to 30 identical ultrasound guidance claims for a single patient office visit. DOJ (SDAL)

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

June 16, 2017

Pennsylvania-based skilled nursing facility operator Genesis Healthcare Inc. agreed to pay roughly $53.6 million to settle charges that companies and facilities acquired by Genesis violated the False Claims Act by causing the submission of false claims to government health care programs for medically unnecessary therapy and hospice services, and grossly substandard nursing care. The allegations originated in a whistleblower lawsuit filed under the qui tam provisions of the False Claims Act by Joanne Cretney-Tsosie, Jennifer Deaton, Kimberley Green, Camaren Hampton, Teresa McAree, Terri West, and Brian Wilson, former employees of companies acquired by Genesis. They collectively will receive a whistleblower award of $9.67 million from the proceeds of the government's recovery. DOJ

Tagged in: FCA Federal, Home Health and Hospice, Lack of Medical Necessity, SNF, Whistleblower Case, Whistleblower Rewards,

June 7, 2017

Texas-based medical and physical therapy provider Union Treatment Center agreed to pay $3 million to settle charges it violated the False Claims Act by defrauding the federal workers’ compensation (FECA) program.  The company will also waive claims for payment exceeding $1.6 million and be permanently excluded from participating in federal health care programs.  According to the government, UTC fraudulently billed the FECA program for services it did not render, routinely overcharged for medical examinations, falsely inflated the time patients spent in therapy, billed for unnecessary services and supplies, and paid kickbacks in exchange for patient referrals.  The allegations originated in a whistleblower lawsuit filed under the qui tam provisions of the False Claims Act. DOJ (WDTX)

Tagged in: FCA Federal, Lack of Medical Necessity, Medical Billing Fraud, Other Government Health Programs, Whistleblower Case, Whistleblower Rewards,

May 11, 2017

Benefits management company Carecore National LLC agreed to pay $54 million to settle charges of violating the False Claims Act by submitting Medicare and Medicaid claims for medical diagnostic procedures without properly assessing whether they were necessary or reasonable.  CareCore provides utilization management services including determinations of medical necessity to New York Medicaid Managed Care Organizations (MCOs). The agreement settles allegations that CareCore instituted a scheme to auto-approve or “Process As Directed” (“PAD”) hundreds of radiology service requests on a daily basis, deeming those diagnostic services as reasonable and medically necessary, even though there had been no evaluation of those cases by the appropriate medical personnel. Of the $54 million, $18 million will go to 20 state Medicaid programs. The allegations originated in a whistleblower lawsuit filed under the qui tam provisions of the False Claims Act.  The whistleblower will receive a yet-to-be-determined whistleblower award from the proceeds of the government's recovery. DOJ (SDNY); NY, FL

Tagged in: FCA Federal, Laboratory and IDTF, Lack of Medical Necessity, Whistleblower Case, Whistleblower Rewards,

May 2, 2017

North Carolina-based Piedmont Pathology agreed to pay $601,000 to settle allegations it violated the False Claims Act by submitting false claims to Medicare and Medicaid for medically unnecessary procedures. The allegations originated in a whistleblower lawsuit filed under the qui tam provisions of the False Claims Act by former Piedmont pathologist Dr. Kim Geisinger. She will receive a whistleblower award of roughly $120,000. DOJ (WDNC)

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

May 2, 2017

Maine dentist Joseph W. Griffin agreed to pay $90,000 to resolve allegations he violated the False Claims Act by submitting submitted false claims to MaineCare (Maine’s Medicaid program) for dental services not rendered, were medically unnecessary, or were so inadequately documented in the patient’s medical record as to be unreviewable. DOJ (DME)

Tagged in: Lack of Medical Necessity, Medicaid, SEC Whistleblower Reward Program, Whistleblower Case,

May 1, 2017

Kansas City area chiropractor Brian Schnitta and his clinic, Natural Way Chiropractic Center, agreed to pay roughly $1 million to settle allegations they violated the False Claims Act by charging Medicare for treatments for peripheral neuropathy not medically necessary or not otherwise covered by the program. DOJ (DKS)

Tagged in: Chiropractic, FCA Federal, Lack of Medical Necessity, Medicare,

May 1, 2017

Memphis-based Poplar Healthcare PLLC and Poplar Healthcare Management, LLC agreed to pay $897,640 to resolve allegations they violated the False Claims Act by billing the government directly and through a subsidiary known as GI Pathology for diagnostic tests not medically necessary. The allegations originated in a whistleblower lawsuit filed under the qui tam provisions of the False Claims Act by former Poplar pathologist Gordon Wang. He will receive a whistleblower award of roughly $206,000 from the proceeds of the government's recovery. DOJ (DRI)

Tagged in: FCA Federal, Laboratory and IDTF, Lack of Medical Necessity, Whistleblower Case, Whistleblower Rewards,

April 28, 2017

New Jersey-based Quest Diagnostics Inc. agreed to pay $6 million to resolve charges that Berkeley HeartLab Inc., which Quest acquired in 2011, violated the False Claims Act by paying kickbacks to physicians and patients to induce the use of Berkeley for blood testing services and by charging for medically unnecessary tests. The allegations originated in a whistleblower lawsuit filed under the qui tam provisions of the False Claims Act by Dr. Michael Mayes. He will receive a yet-to-be-determined whistleblower award from the proceeds of the government's recovery. DOJ

Tagged in: Anti-Kickback and Stark, FCA Federal, Laboratory and IDTF, Lack of Medical Necessity, Whistleblower Case, Whistleblower Rewards,

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