Lack of Medical Necessity

October 9, 2015

Cincinnati-based West Chester Hospital and its parent company, UC Health, agreed to pay $4.1 million to settle allegations that West Chester Hospital violated the False Claims Act by billing federal health care programs for medically unnecessary spine surgeries.  The challenged surgeries were performed between 2009 and 2013 by Dr. Abubakar Atiq Durrani, a surgeon from Mason, Ohio, who had admitting privileges at West Chester Hospital and who was arrested in July 2013 but allegedly fled the country and remains a fugitive.  The allegations first arose in a whistleblower lawsuit filed by former patients of Durrani under the qui tam provisions of the False Claims Act.  They will receive a whistleblower award of approximately $800,000 from the federal share of the settlement.  DOJ

October 8, 2015

Evelio Fernandez Penaranda, owner of Miami-based Naranja Pharmacy Inc., was sentenced to 46 months in prison and to pay $1,876,241 in restitution for his role in the submission of more than $1.8 million in fraudulent claims to Medicare.  According to his guilty plea, Naranja Pharmacy submitted fraudulent claims to Medicare for prescription drugs not prescribed by physicians, not medically necessary and not provided to Medicare beneficiaries. DOJ

October 2, 2015

Guardian Hospice of Georgia LLC, Guardian Home Care Holdings Inc.and AccentCare Inc. agreed to pay $3 million to resolve allegations they knowingly submitted false claims to Medicare for hospice patients who were not terminally ill.  The allegations originated in a whistleblower lawsuit filed by former Guardian employees Rose Betts and Jennifer Williams under the qui tam provisions of the False Claims Act.  Ms. Betts and Ms. Williams will receive a whistleblower award of approximately $510,000.  DOJ

October 1, 2015

Nurses’ Registry and Home Health Corporation and the Estate of its former owner, the deceased Lennie House, agreed to pay $16 million to resolve allegations that Nurses’ Registry, at the direction of Lennie House, violated the False Claims Act by fraudulently billing Medicare for medically unnecessary home health services and for services tainted by kickbacks provided by the company and House to local physicians and others who referred patients to Nurses’ Registry.  According to the government, Nurses’ Registry falsified medical records to make it appear as if patients had a medical need for skilled nursing or therapy services, or appear as if the patients were homebound.  In addition to billing Medicare for unnecessary or non-reimbursable home health services, Nurses’ Registry and House provided tickets to athletic events and concerts, and provided other things of value, to doctors and referral sources in order to induce or reward patient referrals.  The allegations originated in a whistleblower lawsuit filed by former employees Alisia Robinson-Hill and David Price under thequi tam provisions of the False Claims Act.  They will receive a yet-to-be-determined whistleblower award from the settlement proceeds.  DOJ (KY)

September 29, 2015

Delaware-based St. Francis Hospital agreed to pay roughly $4 million to the US and $200,000 to the State of Delaware to resolve charges it violated the False Claims Act by improperly billing Medicare and Medicaid for patients admitted into its inpatient rehabilitation unit in Wilmington, Delaware between 2007 and 2010, when admission was not medically necessary and/or the services provided did not fully qualify for reimbursement.  The settlement agreement also resolves separate allegations that St. Francis employed an individual who was excluded from participating in any Federal health care programs.  DOJ (DE)

September 28, 2015

American Access Care Holdings, LLC agreed to pay $3,594,791 to resolve allegations it violated the False Claims Act by improperly billing Medicare and Medicaid for multiple percutaneous transluminal angioplasties performed during the same patient encounter and improperly submitting claims to Medicare and Medicaid for procedures performed during follow-up visits that were not medically necessary.  The conduct addressed by the settlement occurred prior to AAC’s merger with Fresenius Vascular Care, Inc. in October 2011. DOJ (CT)

September 10, 2015

Tennessee-based non-profit hospice care provider Alive Hospice, Inc.paid roughly $1.5 million to reimburse the government for alleged violations of the False Claims Act through overbilling of Medicare and TennCare for hospice services.  According to the government, Alive submitted claims to Medicare and TennCare for general inpatient hospice care for patients who did not qualify for that care.  The allegations originated in a whistleblower lawsuit filed by Linda Anderson, a triage nurse who previously worked for Alive, under the qui tam provisions of the False Claims Act. She will receive a whistleblower award of $263,197. Whistleblower Insider

August 31, 2015

Laran Lerner, a Detroit-area physician who prescribed unnecessary controlled substances and billed for unperformed office visits and diagnostic testing, pleaded guilty for his role in a $5.7 million health care fraud scheme.  DOJ

August 25, 2015

A federal jury in Miami convicted Roger Rousseau, former medical director of Health Care Solutions Network Inc. (HCSN), and three HCSN therapists for their roles in a scheme to fraudulently bill Medicare and Florida Medicaid more than $63 million.  HCSN is a now-defunct partial hospitalization program that purported to provide intensive treatment for mental illness.  According to the evidence presented at trial, HCSN billed Medicare and Medicaid for mental health services that were not medically necessary or never provided and paid kickbacks to assisted living facility owners and operators in Miami who, in exchange, referred beneficiaries to HCSN.  DOJ

August 19, 2015

Yaroslav (Steven) Proshak, former owner of Southern California ambulance company ProMed Medical Transportation, was convicted of health care fraud charges in connection with a Medicare fraud scheme of at least $2.4 million.  According to the evidence, Proshak and two of his managers conspired to bill Medicare for ambulance transportation services for individuals whom the defendants knew did not need such services.  They also instructed EMTs who worked at ProMed to conceal the true medical conditions of patients they were transporting by altering requisite paperwork and creating fraudulent documents to justify the transportation services.  DOJ