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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:

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November 19, 2015

Florida-based hospice company Hospice of Citrus County agreed to pay roughly $3 million to settle charges the company violated the False Claims Act by knowingly billing Medicare and Medicaid for medically unnecessary and undocumented hospice services.  The allegations resolved included liability under the False Claims Act.  Specifically, the government alleged the company treated at least 52 patients with lengths of stay in excess of 1,000 days and either knowingly or recklessly failed to document a valid basis for the initial start of hospice care and/or subsequent hospice coverage.  The failure in documentation included no support for the length of hospice services; patient files that failed to document basic patient characteristics; and patient records that were either unsigned or signed with inconsistent practitioner information.  In some cases, patients were admitted to HOCC simply because their spouse was in hospice care.  DOJ (MDFL)

November 18, 2015

Deaconess Home Health, Inc. (formerly known as Outreach Home Health) and its owner, Lazarus Bonilla, agreed to pay $3,724,000 to resolve charges they violated the False Claims Act through the false billing of personal care worker services to the Wisconsin Medicaid Program.  Specifically, the defendants (1) intentionally recruited patients for personal care services without regards to whether the services were medically necessary; (2) instructed nurses employed by Deaconess to routinely inflate, without regard to medical necessity, the assessment of the patient that was provided to the Medicaid program; (3) failed to conduct required supervisory visits to ensure that services were in fact being provided, that services continued to be medically necessary, and that any services provided were appropriate for the needs of the patient; and (4) hired physicians to act as medical directors to sign plans of care for patients on whom they had not completed a physical examination.  The allegations first arose in three whistleblower lawsuits filed under the qui tam provisions of the False Claims Act.  Two of the whistleblowers are former employees of Deaconess.  The whistleblowers collectively will receive a whistleblower award of approximately $600,000.  (DOJ (EDWI)

November 16, 2015

HCA Holdings, Inc. (including affiliated entities Hospital Corporation of America; Parallon Business Solutions, LLC; West Florida Regional Medical Center, Inc.; HCA Health Services of Florida, Inc.; Regional Medical Center Bayonet Point; HCA Health Services of Florida, Inc.; New Port Richey Hospital, Inc.; and Medical Center of Trinity) agreed to pay $2 million to resolve charges of violating the False Claims Act through billing Medicare for unnecessary lab tests and double billing for fetal testing.  The allegations first arose in a whistleblower lawsuit by HCA employee Kelly Oxendine under the qui tam provisions of the False Claims Act.  The whistleblower will receive a whistleblower award of roughly $400,000 from the government’s recovery.  DOJ(SC)

November 13, 2015

Tamara Esponda, owner of Miami-area pharmacy Biomax Pharmacy Inc., was sentenced to 42 months in prison and to pay roughly $1.6 million in restitution for her role in the submission of more than $1.5 million in fraudulent claims to Medicare Part D.  According to admissions made in connection with Esponda’s guilty plea, Biomax Pharmacy submitted fraudulent claims to Medicare for prescription drugs that were not prescribed by physicians, not medically necessary and not provided to Medicare beneficiaries.  Esponda further admitted that in perpetrating this fraud she and her accomplices used the beneficiaries’ and doctors’ Medicare identification numbers without their consent.  DOJ

October 30, 2015

The Department of Justice reached 70 settlements involving 457 hospitals in 43 states for more than $250 million related to cardiac devices implanted in Medicare patients in violation of Medicare coverage requirements.  The devices, called implantable cardioverter defibrillators (ICDs), are electronic devices implanted near and connected to the heart to detect and treat chaotic, extremely fast, life-threatening heart rhythms, called fibrillations, by delivering a shock to the heart, restoring the heart’s normal rhythm.  Only patients with certain clinical characteristics and risk factors qualify for an ICD covered by Medicare.  According to the government, from 2003 to 2010 each of the settling hospitals implanted ICDs during periods prohibited by the Medicare’s National Coverage Determination.  Most of the settlements originated from allegations first raised in a whistleblower lawsuit brought under the qui tam provisions of the False Claims Act by Leatrice Ford Richards, a cardiac nurse, and Thomas Schuhmann, a health care reimbursement consultant.  They have so far received a combined whistleblower award of more than $38 million from the settlements.  The Department of Justice is continuing to investigate additional hospitals and health systems.  DOJ

October 26, 2015

Valentina Kovalienko, the owner of two Brooklyn medical clinics, pleaded guilty to, and agreed to forfeit almost $30 million for, her role in a $55 million health care fraud and money laundering conspiracy.  According to her admissions, from approximately February 2008 to February 2011, Kovalienko and others executed a scheme in which patients were paid cash kickbacks to subject themselves to medically unnecessary physical and occupational therapy, diagnostic tests and office visits that were not performed by licensed professionals, and for which the clinics billed Medicare and Medicaid.  Kovalienko also admitted that to support the fraudulent claims she paid occupational and physical therapists to falsify patient charts and billing records.  DOJ

October 19, 2015

Millennium Health (formerly Millennium Laboratories) agreed to pay $256 million to the federal and state governments to resolve charges it billed Medicare for medically unnecessary urine drug and genetic testing.  According to the government, Millennium caused physicians to order excessive numbers of urine drug tests, in part through the promotion of “custom profiles,” which instead of being tailored to individual patients were in effect standing orders that caused physicians to order large number of tests without an individualized assessment of each patient’s needs.  The government further alleged that Millennium’s provision of free point of care urine drug test cups to physicians — expressly conditioned on the physicians’ agreement to return the urine specimens to Millennium for hundreds of dollars’ worth of additional testing — violated the Stark Law and the Anti-Kickback Statute.  The case originated from several whistleblower lawsuits filed under the qui tam provisions of the False Claims Act.  Whistleblowers in the underlying cases will receive awards totalling roughly $32 million.  DOJ GA , FL, WA

October 16, 2015

A federal jury in Los Angeles convicted Amalya Cherniavsky and her husband, Vladislav Tcherniavsky, for conspiracy to commit health care fraud in connection with a $1.5 million Medicare fraud scheme.  The evidence at trial demonstrated that Cherniavsky owned JC Medical Supply, a purported durable medical equipment supply company, and that she co-operated the company with her husband, Tcherniavsky, and that they paid illegal kickbacks to patient recruiters in exchange for patient referrals.  The evidence further showed that the defendants 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

October 15, 2015

Shreveport, Louisiana community mental health center Westwood Mental Health LLC, and its parent company MedSouth LLC, agreed to pay $3.5 million to settle False Claims Act and Anti-Kickback Statute allegations that Westwood falsified patient records, billed for services not medically necessary, billed for services that were not rendered, provided bribes to Medicare beneficiaries who did not qualify for partial hospitalization services and provided bribes and/or kickbacks to employees to further or conceal the fraud.  DOJ (WDLA)

October 14, 2015

Santiago Borges, Erik Alonso and Cristina Alonso, all of Miami, pleaded guilty to federal healthcare fraud charges.  Borges owned the now-defunct mental health centers R&S Community Mental Health Inc. and St. Theresa Community Mental Health Center Inc., and was an investor in New Day Community Mental Health Center LLC .  Erik Alonso was the clinical director of all three centers.  Cristina Alonso was a therapist at R&S.  They admitted the clinics billed Medicare for costly partial hospitalization program services that were not medically necessary or not provided to patients.  Borges also admitted he paid kickbacks to patient recruiters who, in exchange, referred beneficiaries to the centers.  DOJ
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