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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:

Page 5 of 48

July 22, 2022

Metric Lab Services, LLC, Metric Management Services LLC, Spectrum Diagnostic Labs LLC, and two of their owners, Sherman Kennerson and Jeffrey Madison, will pay $5.7 million to resolve allegations of False Claims Act violations. In their genetic testing fraud scheme, Metric and Spectrum paid kickbacks to certain marketers who solicited generic testing samples from Medicare beneficiaries, with false physician attestations that the testing was medically necessary. Kennerson and Madison both pled guilty to one count of conspiracy to defraud the U.S. and are currently awaiting sentencing. DOJ, NJ USAO

Tagged in: Anti-Kickback and Stark, FCA Federal, Healthcare Fraud, Laboratory and IDTF, Lack of Medical Necessity, Medicare,

July 20, 2022

Texas-based clinical laboratory Inform Diagnostics, Inc., formerly known as Miraca Life Sciences, Inc., has agreed to pay $16 million to resolve allegations of violating the False Claims Act.  Inform admitted that it had a policy of conducting additional tests on biopsy specimens without an individualized determination on whether additional tests were medically necessary, then submitting bills for those unauthorized and unnecessary tests to Medicare and other federal healthcare programs.  USAO MA

Tagged in: FCA Federal, Healthcare Fraud, Laboratory and IDTF, Lack of Medical Necessity, Medicare, Other Government Health Programs,

June 16, 2022

A Florida man who was convicted of defrauding Medicare of over $20 million and evading taxes has been sentenced to 14 years in prison and ordered to pay $4 million in restitution to the IRS.  As the owner and operator of multiple telemarking and telemedicine companies, Marc Sporn marketed and sold signed prescription orders for medically unnecessary genetic tests, in exchange for illegal kickbacks from pharmacies and laboratories.  USAO SDFL

Tagged in: Criminal Proceedings, Healthcare Fraud, Laboratory and IDTF, Lack of Medical Necessity, Medicare, Tax Fraud,

June 3, 2022

Rodney L. Yentzer will pay $900,000 for violating the False Claims Act. Through Pain Medicine of York, a group of clinics he controlled, Yentzer caused the submission of false claims for payment to Medicare for urine drug tests that were not medically reasonable or necessary and were not used to aid in the diagnosis and treatment of patients. He is excluded from participation in all federal health care programs for 22 years. In March of 2022, Yentzer pleaded guilty to Health Care Fraud, Money Laundering, and Theft of Public Money for defrauding Medicare, Medicaid, and the U.S. Department of Health and Human Services between 2016 and 2020. USAO MDPA

Tagged in: FCA Federal, Healthcare Fraud, Laboratory and IDTF, Lack of Medical Necessity, Medicaid, Medical Billing Fraud, Medicare, Other Government Health Programs, Provider Fraud,

May 18, 2022

Pat Truglia will spend 120 months in prison, forfeit over $9.4 million, and will pay restitution of $33.7 million for conspiring to defraud Medicare, TRICARE, and CHAMPVA, among others, of approximately $50 million through their fraudulent billing scheme. The scheme involved offering, paying, soliciting, and receiving kickback for durable medical equipment—in this case, braces. Truglia and his conspirators obtained DME orders for Medicare and other federal healthcare program beneficiaries by running multiple call centers, which paid kickbacks and bribes to telemedicine companies, who then paid doctors to write medically unnecessary orders. The orders were filled by Truglia’s companies, who then fraudulently billed the healthcare programs. USAO NJ

Tagged in: Anti-Kickback and Stark, Criminal Proceedings, Healthcare Fraud, Lack of Medical Necessity, Medical Devices and DME, Medicare, Other Government Health Programs, Provider Fraud,

April 28, 2022

Donald Woo Lee, a California-based doctor who recruited Medicare beneficiaries to his clinics, falsely diagnosed them and provided them with medically unnecessary procedures, and then submitted upcoded bills for those procedures to Medicare, has been sentenced to nearly 8 years in prison after being found guilty of seven counts of healthcare fraud.  In addition to submitting approximately $12 million in false claims to Medicare, for which he received $4.5 million in reimbursement, Lee also repackaged and reused single-use catheters on his patients.  DOJ

Tagged in: Criminal Proceedings, Healthcare Fraud, Lack of Medical Necessity, Medicare, Provider Fraud, Upcoding,

April 26, 2022

A former pharmacist in Mississippi named Mitchell Barrett has been sentenced to 10 years in prison and ordered to pay restitution as well as forfeit all assets stemming from a $180 million healthcare fraud scheme against TRICARE and other health benefit programs.  Barrett had adjusted prescription formulas to ensure the highest possible reimbursement, solicited recruiters to procure prescriptions for expensive compounded drugs, paid those recruiters a commission based on reimbursements from TRICARE, routinely waived copayments required to be paid by TRICARE beneficiaries, and took steps to disguise the waived payments.  DOJ

Tagged in: Compounding Pharmacy Fraud, FCA Federal, Healthcare Fraud, Lack of Medical Necessity, Other Government Health Programs, Pharma Fraud,

April 12, 2022

Providence Health & Services Washington has agreed to pay $22.7 million to settle allegations of submitting false claims to Medicare, Medicaid, and TRICARE.  According to an unnamed whistleblower, who will receive a $4.2 million relator’s share, the hospital allegedly gave their neurosurgeons volume-based financial incentives to perform complex surgeries, thereby incentivizing two neurosurgeons to perform an excessive number of complex surgeries on inappropriate candidates without regard to medical necessity or patient safety, and ultimately causing an excessive level of complications.  USAO EDWA

Tagged in: FCA Federal, FCA State, Healthcare Fraud, Lack of Medical Necessity, Provider Fraud, Whistleblower Case, Whistleblower Rewards,

April 12, 2022

Physician Partners of America LLC (PPOA), its founder Rodolfo Gari, and its former chief medical officer Dr. Abraham Rivera, have agreed to pay $24.5 million to settle allegations of violating the Stark Law, False Claims Act, and Financial Institutions Reform, Recovery and Enforcement Act (FIRREA).  The settlement resolved claims by whistleblowers Donald Haight, Dawn Baker, Dr. Harold Cho, Dr. Venus Dookwah-Roberts, and Dr. Michael Lupi, all currently or formerly employed with PPOA.  According to the whistleblowers and the government, PPOA allegedly billed Medicare and Medicaid for medically unnecessary testing, paid illegal kickbacks to its physician employees, and made false statements on a loan from the Paycheck Protection Program.  USAO MDFL

Tagged in: Anti-Kickback and Stark, FCA Federal, Government Programs Fraud, Healthcare Fraud, Lack of Medical Necessity, Medicaid, Medicare, Whistleblower Case,

March 31, 2022

Clinical laboratory Radeas LLC has agreed to pay $11.6 million to resolve claims that it submitted false claims to Medicare for medically-unnecessary urine drug tests.  As part of the settlement agreement, Radeas admitted that it regularly performed and billed Medicare for essentially simultaneous presumptive qualitative drug testing and confirmatory quantitative drug testing.  Without physician review of a presumptive test result, the separate, simultaneous confirmatory test was often not necessary.  Radeas also admitted that it paid third-party sales organizations based on the volume of UDT referrals in violation of the Anti-Kickback Statute.  USAO MA

Tagged in: Anti-Kickback and Stark, Healthcare Fraud, Laboratory and IDTF, Lack of Medical Necessity, Medicare,

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