Lack of Medical Necessity

January 12, 2017

Texas announced a settlement with MB2 Dental Solutions (MB2) and 21 affiliated pediatric dental practices. MB2 agreed to pay the United States and the State of Texas $8.45 million for alleged violations of the federal False Claims Act (FCA) and the Texas Medicaid Fraud Prevention Act (TMFPA). Three lawsuits were resolved with this settlement alleging that MB2 knowingly submitted claims for children’s dental services which were either not performed or were provided after false identification was used. The claims also involved illegal kickbacks to Medicaid beneficiaries and their families, marketers and marketing entities. The allegations were brought to the attention of the U.S. and Texas authorities by whistleblowers who filed one lawsuit under the FCA and two under the TMFPA. TX

December 15, 2016

Raciel Leon, manager of Mercy Home Care Inc. and a billing employee for D&D&D Home Health Care Inc. was convicted for his role in a $2.5 million Medicare fraud scheme. According to evidence presented at trial, Leon and his co-conspirators used the companies to submit false claims to Medicare that were based on services that were not medically necessary, not actually provided and for patients that were procured through the payment of illegal kickbacks to doctors and patient recruiters.  DOJ

December 7, 2016

Not-for-profit regional hospital South Miami Hospital agreed to pay approximately $12 million to settle allegations that it violated the False Claims Act by submitting false claims to federal healthcare programs for medically unnecessary electrophysiology studies and other procedures allegedly performed by Dr. John R. Dylewski.  The allegations originated in a whistleblower lawsuit filed under the qui tam provisions of the False Claims Act by South Miami Hospital doctors James A. Burks and James D. Davenport.  They will receive a whistleblower award of roughly $2,748,500 from the proceeds of the government's recovery.  DOJ (SDFL)

December 7, 2016

Jacksonville, Florida-based orthopedic medical group Southeast Orthopedic Specialists agreed to pay roughly $4.5 million to resolve allegations that it violated the False Claims Act by billing federal healthcare programs for services that were not medically necessary.  DOJ (MDFL)

December 7, 2016

Lifepoint Dental Group, LLC, and its owners Aaron Blass, Angelina Blass, Mindy Richtsmeier, and Brad Richtsmeier, agreed to pay more than $300,000 to settle allegations that they violated the False Claims Act by submitting claims for dental procedures, including scalings and root planings, that were either medically unnecessary or did not happen.  The allegations originated in a whistleblower lawsuit filed by two former Lifepoint employees under the qui tam provisions of the False Claims Act.  The whistleblowers will receive a yet-to-be-determined whistleblower award from the proceeds of the government's recovery.  DOJ (NDIA)

Radiology Practice - Healthcare Fraud/Unnecessary Testing ($10.5M)

Constantine Cannon represented two whistleblowers in a False Claims Act case alleging New York-based Zwanger-Pesiri Radiology improperly billed Medicare for testing that was medically unnecessary or never performed.  In November 2016, the company agreed to pay $10.5 million to settle both criminal and civil charges.  Our clients received a whistleblower award of more than $1 million.  Read more -- Newsday, DOJ, PR Newswire, CC.

September 28, 2016

Pennsylvania-based hospital chain Vibra Healthcare LLC agreed to $32.7 million to resolve claims it violated the False Claims Act by billing Medicare for medically unnecessary services.  According to the government, Vibra admitted numerous patients to five of its long term care hospitals and one of its inpatient rehab facilities who did not demonstrate signs or symptoms that would qualify them for admission.  In addition, Vibra allegedly extended the stays of its long term care patients without regard to medical necessity, qualification and/or quality of care.  In some instances, Vibra allegedly ignored the recommendations of its own clinicians, who deemed these patients ready for discharge.  The allegations originated in a whistleblower lawsuit filed by Sylvia Daniel, a former health information coder at Vibra Hospital of Southeastern Michigan, under the qui tam provisions of the False Claims Act.  She will receive a whistleblower award of at least $4 million from the proceeds of the government's recovery.  Whistleblower Insider