Lack of Medical Necessity

February 6, 2015

Oklahoma-based Hospice care provider Good Shepherd Hospice Inc.agreed to pay $4M to resolve allegations it submitted false claims for hospice patients who were not terminally ill. Specifically, the government contended Good Shepherd pressured staff to meet admissions and census targets and paid bonuses to staff, including hospice marketers, admissions nurses and executive directors, based on the number of patients enrolled even if they were not eligible for hospice care. The settlement resolves allegations first raised by former Good Shepherd employees Kathi Cordingley and Tracy Jones in a whistleblower lawsuit they filed under the qui tam provisions of the False Claims Act. They will receive a whistleblower award of approximately $680,000. DOJ

February 3, 2015

Ernesto Fernandez pleaded guilty and was sentenced to 10 years in prison in connection with a long-running $6.2M Medicare fraud scheme involving Miami-based home health care agency Professional Medical Home Health LLC. Fernandez was an owner and operator of Professional Home Heath and also the owner and operator of two other South Florida home health agencies where he caused patient documentation to be falsified, and planned, organized and oversaw the submission of fraudulent claims to the Medicare program. Juan Valdes also pleaded guilty to the same scheme and was sentenced to 2 years in prison. He was a patient recruiter for Professional Home Health and solicited kickbacks and bribes from the owners and operators of Professional Home Health in exchange for providing beneficiaries to allow Professional Home Health to bill Medicare for home health services that were not medically necessary or not provided. Fernandez and Valdes are the seventh and eighth defendants to be sentenced in connection with the fraudulent schemes at Professional Home Health. DOJ

January 29, 2015

Four South Florida residents were sentenced in connection with a long-running $6.2M Medicare fraud scheme involving Professional Medical Home Health LLC, a Miami home health care agency operated for the purpose of billing the Medicare program for expensive physical therapy and home health services that were not medically necessary or actually provided. Dennis Hernandez was sentenced to 120 months in prison and to pay $1,438,186; Jose Alvarez was sentenced to 120 months in prison and to pay $2,972,570; Joel San Pedro was sentenced to 97 months in prison and to pay $4,938,432; Alina Hernandez was sentenced to 24 months in prison and to pay $204,526.05. DOJ

January 26, 2015

Ramon Regueira, the owner and operator of a Miami home health care agency Nation’s Best Care Home Health Corp. was sentenced to 106 months in prison and to pay $21M for his participation in a $30M Medicare fraud scheme. Regueira admitted he and his co-conspirators operated Nation’s Best for the purpose of billing the Medicare program for, among other things, expensive physical therapy and home health care services that were not medically necessary or not provided. He further admitted he and his co-conspirators paid kickbacks and bribes to patient recruiters who provided patients to Nation’s Best, as well as prescriptions, plans of care (POCs) and certifications for medically unnecessary therapy and home health services.DOJ

January 26, 2015

Kentucky-based ambulance services company Lafferty Enterprises, LLC(d/b/a Trans-Star Ambulance Services) agreed to pay $948,000 to settle charges it violated the False Claims Act by billing federal health care programs for medically unnecessary services over the course of several years. According to the government, from February 2006 until December 2012, the company transported Medicare patients to and from dialysis clinics by ambulance when an ambulance transport was not medically necessary. The charges originated from a whistleblower lawsuit filed by Kevin Fairlie under the qui tam provisions of the False Claims Act. He will receive a whistleblower award of $189,600. DOJ

January 14, 2015

Michigan physician Paula Williamson was sentenced to 15 months in prison and to pay more than $1M in restitution for her role in a $2.1M home health care fraud scheme involving Michigan-based home health care agency AMB Healthcare Inc. According to her plea agreement, Williamson conspired with others to commit health care fraud by referring Medicare beneficiaries for home health care services that were medically unnecessary and never provided. She also falsified documents used to support the false Medicare claims. DOJ

January 9, 2015

Felix Gonzalez, owner of Miami-based home health care company AA Advanced Care Inc. pleaded guilty in connection with a $32 million Medicare fraud scheme. Specifically, Gonzalez admitted he and his co-conspirators operated AA Advanced for the purpose of billing Medicare for, among other things, expensive physical therapy and home health care services not medically necessary or not provided at all. He also admitted he paid kickbacks and bribes to patient recruiters in exchange for patient referrals, prescriptions, plans of care (POCs) and certifications for medically unnecessary therapy and home health services. DOJ

December 17, 2014

Mark Morad and Dr. Divini Luccioni, both of Louisiana, pleaded guilty to their role in a $56M Medicare fraud scheme. According to court documents, Morad directed the scheme through multiple New Orleans-area companies he owned, including Interlink Health Care Services Inc.,Memorial Home Health Inc., Lakeland Health Care Services Inc., Lexmark Health Care LLC, and Med Rite Pharmacy Inc. Morad paid kickbacks to recruiters who canvassed New Orleans neighborhoods for Medicare beneficiary numbers, which Morad then used to bill Medicare for services that were not medically necessary or not provided. Dr. Luccioni admitted that he signed home health referrals and wrote DME prescriptions that were used to support these fraudulent billings. DOJ

November 12, 2014

Home healthcare agency CareAll Management LLC agreed to pay $25M to settle charges it violated the False Claims Act by submitting false and upcoded home healthcare billings to Medicare and Medicaid. According to the government, between 2006 and 2013, CareAll overstated the severity of patients’ conditions to increase billings and billed for services that were not medically necessary and rendered to patients who were not homebound. The current allegations first arose in a whistleblower lawsuit filed by Toney Gonzales under the qui tam provisions of the False Claims Act.  Gonzales will receive a whistleblower award in an undisclosed amount.  Whistleblower Insider

October 22, 2014

Tayyab Aziz, founder of three Detroit-area home health agencies Prestige Home Health Services Inc., Royal Home Health Care Inc., and Platinum Home Health Services Inc. pleaded guilty for his role in a $22M home health care fraud scheme. Specifically, Aziz admitted he and his co-conspirators submitted fraudulent claims to Medicare for services that were medically unnecessary or never performed. They also submitted claims for services purportedly provided to Medicare beneficiaries who were recruited through illegal kickbacks paid to the patients and recruiters. DOJ