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Medicaid

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December 3, 2019

In the second settlement to come out of a federal investigation into the generic pharmaceutical industry, Rising Pharmaceuticals Inc. has agreed to pay over $4 million to settle civil and criminal charges stemming from violations of the False Claims Act and Anti-Kickback Statute.  In the criminal case, Rising allegedly teamed up with a competing generic drug manufacturer to fix prices and divide up the market for a hypertension drug, Benazepril HCTZ, while in the civil case, the company allegedly paid and received illegal remuneration through similar arrangements with another generic drug manufacturer.  Under the newly signed deferred prosecution agreement, Rising has agreed to cooperate fully with the ongoing investigation.  DOJ; USAO EDPA

November 22, 2019

Ave Maria Family Practice PLLC and its principal, Dr. Dorothy Agbafe-Mosley, have agreed to pay $1.25 million to the State of North Carolina to resolve claims that they falsely billed the state's Medicaid program for addiction treatment services allegedly provided to Medicaid beneficiaries.  In fact, the services were not medically necessary, had no supporting clinical documentation, or were otherwise performed in violation of Medicaid policy.  NC

Government Audit of Chronic Care Management Services Raises Serious Questions About Proposed Anti-Kickback Statute Safe Harbors

Posted  11/22/19
stethoscope on top of money and coins
The U.S. Department of Health and Human Services is engaged in what it calls a “Regulatory Sprint to Coordinated Care,” in order to, in the words of HHS Deputy Secretary Eric Hargan, “update, reform, and cut back our regulations to allow innovation toward a more affordable, higher quality, value-based healthcare system.”  On October 9, 2019, as part of this effort to “cut back” on regulations to advance...

November 15, 2019

Pharmaceutical manufacturer Lupin Limited and related entities, together with company executives Vinita Gupta and Robert Hoffman, will pay $63 million to Texas to resolve claims under the Texas Medicaid Fraud Prevention Action that they reported inflated drug prices to the state's Medicaid program in order to receive excess reimbursements.  The investigation of Lupin was initiated by a whistleblower lawsuit filed by Expess Med Pharmaceuticals, Inc.  TX

November 14, 2019

Following a guilty plea in 2018, Sandra Haar was sentenced to five years in prison and has agreed to sell 13 properties, including former clinic properties, to resolve civil claims under the False Claims Act that she and the non-profit provider of health and dental services she ran, Horisons Unlimited, submitted fraudulent claims to Medi-Cal, including claims for services rendered by unlicensed providers, claims for services that were not rendered at all, and claims for unnecessary services. Haar was also alleged to have received thousands in kickbacks from a laboratory in exchange for sending Horisons patients to the lab. Haar will be excluded from Medicare participation for 20 years; the former Horisons CFO, Norman Haar, will be excluded for 15 years.  USAO ED Cal

November 13, 2019

The Louisiana Department of Health, which manages Louisiana’s Medicaid program, will pay $13.42 million to the federal government to resolve allegations that the state submitted false claims for federal share reimbursement of state Medicaid expenditures for long-term nursing care and hospice care.  The federal government alleged that in anticipation of a reduction in federal payments for such services, the state agency directed its healthcare contractor, Molina Medical Solutions, to pre-bill for nursing home and hospice services in order to receive funds at the existing higher rates.   DOJ

November 7, 2019

Medical device manufacturer Life Spine Inc. has agreed to pay $5.5 million to settle fraud allegations stemming from a qui tam suit, with founder and CEO Michael Butler agreeing pay another $375,000, and VP of business development Richard Greiber agreeing to pay another $115,000.  As part of the settlement, the defendants admitted to paying kickbacks to surgeons and entities between 2012 and 2018 in exchange for their use of Life Spine’s spinal implants, devices, and equipment.  USAO SDNY

November 5, 2019

A home health agency that allegedly defrauded Medicare and Louisiana’s Medicaid program has agreed to pay $2.5 million to settle claims arising from a qui tam suit.  Defendants Health Care Options, Inc., Health Care Options of Lafayette, Inc., Home Care Options Houston, Inc., and Howard Austin, II allegedly submitted reimbursement claims involving non-face-to-face encounters, as required by program rules.  USAO MDLA

October 28, 2019

The State of Illinois has reached a settlement with more than a dozen drug manufacturers alleged to have published inflated "average wholesale prices" for drugs whose purchase was reimbursed by Illinois's Medicaid program at prices based on those false AWPs.  The settlement for $242 million includes Abbott Laboratories, Inc.; Aventis Pharmaceuticals Inc.; Aventis Behring LLC, n/k/a ZLB Behring; B. Braun Medical Inc.; Forest Laboratories, Inc.; GlaxoSmithKline LLC; Johnson & Johnson, Inc.; Janssen Pharmaceutical Products, LP; McNeil-PPC, Inc.; Ortho Biotech Products, LP; Ortho-McNeil Pharmaceutical, Inc.; Novartis Pharmaceuticals Corporation; Pfizer Inc.; Pharmacia Corporation; and TAP Pharmaceutical Products, Inc.  In total, Illinois has settled inflated AWP claims against more than four dozen manufacturers (see, e.g., January 2019 settlement with TEVA Pharmaceuticals), recovering $678 million in total.  IL AG  

October 28, 2019

Sanford Health, Sanford Medical Center, and Sanford Clinic have agreed to pay $20.25 million and enter into a Corporate Integrity Agreement in order to resolve alleged violations of the Anti-Kickback Statute and False Claims Act.  Despite warnings by several physicians that a top neurosurgeon was illegally profiting off his use of implantable medical devices as well as performing medically unnecessary surgeries involving the devices, Sanford did nothing to stop the offender, allowing Medicare and Medicaid to continue being defrauded.  The allegations were raised by Sanford surgeons Drs. Carl Dustin Bechtold and Bryan Wellman, who will share in a $3.4 million cut of the settlement proceeds.  DOJ; USAO SD
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