Lack of Medical Necessity

April 11, 2016

Tennessee-based drug urine screening company PremierTox 2.0, Inc. (previously called Nexus) agreed to pay $2.5 million to resolve allegations it violated the False Claims Act by submitting false claims when billing Medicare, TennCare and Kentucky Medicaid for drug urine screening services.  According to the government, PremierTox had a swapping arrangement under which Nexus gave below cost discounts on its urine drug screen tests to patients in Tennessee without insurance, in exchange for physicians’ referring their patients with Medicare or TennCare coverage to Nexus. The government also contended that in Tennessee Nexus submitted excessive claims to Medicare and TennCare for laboratory testing that was beyond what was medically reasonable and necessary.  The allegations originated in two whistleblower lawsuits filed under the qui tam provisions of the False Claims Act by a former office manager of a pain clinic and the former CEO of PremierTox.  The office manager will receive a whistleblower award of $361,250, and the former CEO will receive a whistleblower award of $56,250.  DOJ (MDTN)

April 11, 2016

Naseem Minhas, the owner and operator of Detroit-area home health care agency TriCounty Home Care Services Inc. pleaded guilty today for his participation in a $4 million health care fraud scheme.  According to admissions made as part of his plea agreement, Minhas paid a physician and recruiters to refer Medicare beneficiaries to TriCounty and sign medical documents falsely certifying that they required home health care.  Minhas, a licensed physical therapist, also admitted that he assisted in creating fake patient files to make it appear as though the patients needed and received services that were unnecessary or not provided.  DOJ

March 25, 2016

Damian Mayol, the president of Miami-based transportation company Transportation Services Providers Inc. was sentenced to 60 months in prison and to pay $26.8 million in restitution (and forfeit the same amount) for his role in a health care fraud scheme involving three mental health centers that resulted in the submission of approximately $70 million in false Medicare claims.  According to evidence presented at trial, Mayol and his co-conspirators used his company to coordinate the payment of illegal kickbacks to recruiters, who in return referred patients to three now-defunct community mental health centers -- R&S Community Mental Health Inc., St. Theresa Community Mental Health Center Inc. and New Day Community Mental Health Center LLC -- for costly partial hospitalization program services that were not medically necessary or not actually provided.  DOJ

March 18, 2016

A federal jury in New Orleans convicted Elaine Davis and Dr. Pramela Ganji for their roles in a $34 million Medicare fraud scheme.  The jury found that Davis, who owned Christian Home Health Care Inc., together with Ganji caused the healthcare company to bill Medicare for home health care services that were not needed and/or not actually provided.  Davis paid employees to recruit new patients and then sent their Medicare information to doctors, including Ganji, to obtain their signatures to certify that the patients qualified to receive home health care services, which trial evidence showed they did not qualify for or need.  DOJ

March 15, 2016

Tennessee-based Southern Tennessee Medical Center agreed to pay roughly $2.5 million to settle charges it violated the False Claims Act by submitting Medicare claims for medically unnecessary days of in-patient geriatric psychiatric services and in-patient geriatric psychiatric services for which a Physician Certification or Recertification was not obtained.  DOJ (MDTN)

March 8, 2016

21st Century Oncology Inc., the nation’s largest physician led integrated cancer care provider, and its wholly owned subsidiary South Florida Radiation Oncology agreed to pay $34.7 million to settle charges they violated the False Claims Act by performing and billing for cancer care procedures that were not medically necessary or properly provided. According to the government, the companies improperly billed for Gamma function procedures — which measure radiation doses — under circumstances where there was no medically appropriate purpose for the treatment.  The allegations leading to the settlement originated in a whistleblower lawsuit filed by Joseph Ting, a former physicist at South Florida Radiation Oncology, under the qui tam provisions of the False Claims Act.  He will receive a whistleblower award of more than $7 million from the proceeds of the government’s recovery.  This settlement follows on the heels of the $19.75 million settlement 21st Century Oncology Inc. subsidiary 21st Century Oncology LLC agreed to pay in December to settle charges of billing for medically unnecessary laboratory urine tests and for paying kickbacks to encourage physicians to order the tests.  Whistleblower Insider

March 1, 2016

Ubert Guillermo Rodriguez, president and owner of Florida-based durable equipment provider G.R. Services Equipment & Supplies Inc., pleaded guilty to conspiracy to commit health care fraud.  According to the government, Rodriguez’s company submitted approximately $2.6 million worth of claims to Medicare seeking reimbursement for durable medical equipment, such as wound care supplies, that was not legitimately prescribed by doctors and was not provided to beneficiaries.  DOJ

February 9, 2016

Miami physician Henry Lora, medical director of Miami-area clinic Merfi Corporation, pleaded guilty for his role in a Medicare fraud scheme that caused more than $20 million in losses.  Lora admitted that in exchange for kickbacks and bribes, he and his co-conspirators wrote prescriptions for home health care and other services for Medicare beneficiaries that were not medically necessary or not provided.  Lora and his co-conspirators also falsified patient records to make it appear as if the beneficiaries qualified for these services.  In March 2014, Isabel Medina, the owner of Merfi, was sentenced to nine years in prison for conspiracy to commit health care fraud.  DOJ

January 29, 2016

Amalya Cherniavsky and her husband Vladislav Tcherniavsky, the former owner and former operator of California-based durable medical equipment supply company JC Medical Supply were sentenced  for their roles in a $1.5 million Medicare fraud scheme.  They were ordered to pay $614,418 in restitution and Tcherniavsky was ordered to serve 51 months in prison.  The evidence at trial demonstrated that they paid illegal kickbacks to patient recruiters in exchange for patient referrals and paid kickbacks to physicians for fraudulent prescriptions—primarily for expensive, medically unnecessary power wheelchairs—which the defendants then used to support fraudulent bills to Medicare.  DOJ