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Medicaid

This archive displays posts tagged as relevant to Medicaid and fraud in the Medicaid program. You may also be interested in our pages:

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Tracking Medicaid Fraud: HHS OIG Releases MFCU Annual Report

Posted  04/2/20
Human Health Services Office of Inspector General Logo
The HHS OIG recently released the Medicaid Fraud Control Units (MFCUs) Fiscal Year 2019 Annual Report, providing a consolidated accounting of the program’s success. MFCUs investigate and prosecute Medicaid fraud and patient abuse or neglect. MFCUs receive referrals from other agencies, the public, or via data mining with OIG approval. The referral is reviewed, an investigation is conducted, and the decision is...

March 11, 2020

The organizer of a $2 million multi-state Medicaid fraud scheme has been sentenced to 11 years in prison and ordered to pay $2.5 million in restitution.  Along with two other co-defendants, Matthew Harrell fraudulently obtained the Medicaid provider number of mental health service providers in Georgia and Florida, as well as the Medicaid member numbers of children in foster care, welfare, and other programs in Louisiana.  Using companies purporting to be mental health providers, the defendants then submitted $3.5 million in false claims and received $2.5 million in reimbursements. Harrell's co-defendants, Nikki Richardson and Tomeka Howard, have also been ordered to serve time and pay restitution.  USAO NDGA

Medicaid Drug Rebate Fraud: Should it be an Enforcement Priority?

Posted  03/10/20
pill container spilled over with pills in the form of a dollar sign
Medicaid has one very intuitive approach to keeping drug prices in check. Drug companies, under a law called the Medicaid Drug Rebate Program, must rebate Medicaid programs any money that resulted from the increased drug prices outpacing inflation. Inflation is benchmarked to either 1990, or the first year a drug came to market, which ever is later. As an example of how this works, imagine a pharmaceutical company...

“Objective Falsity” Is Not Required Under the False Claims Act: A Legally False Opinion May Suffice

Posted  03/6/20
Gavel close-up
In a significant win for whistleblowers, a federal appellate court held this week that, in order to determine liability under the False Claims Act, a whistleblower need not prove that a claim is “objectively” false.  Instead, the Court held that, consistent with common law, a claim can be false under the FCA if based not on objectively verifiable facts, but on non-compliance with statutory or regulatory...

March 4, 2020

STG Healthcare of Atlanta, Inc. and senior executives Paschal Gilley and Mathew Gilley have agreed to resolve fraud allegations by paying $1.75 million.  The case against the hospice was launched by two former employees, Serita Samuel and Miranda Eskridge, who alleged in a qui tam suit that STG Healthcare submitted false claims to Medicare and Medicaid that arose from illegal payments to so-called back-up medical directors, and that were on behalf of patients who were not terminally ill and thus ineligible for palliative care.  GA AG; USAO NDGA

March 2, 2020

The owners and operators of Middlesex Rheumatology in Connecticut, Dr. Crispin Abarientos and his wife Dr. Antonieta Abarientos, have agreed to pay $4.9 million to settle allegations of violating federal and state False Claims Act.  Between 2013 to 2017, the Abarientos allegedly billed Medicaid for an injectable prescription drug called Remicade, which is used to treat rheumatoid arthritis, but then failed to administer the drugs on Medicaid patients.  Instead, they administered them on patients covered by Medicare or the Connecticut State Employees Health Plan, then billed the two providers for the drugs again even though the cost had already been covered by Medicaid.  USAO CT

February 28, 2020

Nursing home chain Diversicare Health Services, Inc. has agreed to pay $9.5 million to resolve whistleblower-brought allegations of submitting claims to Medicare and Medicaid for medically unnecessary rehabilitation therapy services.  According to separate qui tam complaints by former employees, Mary Haggard and Bryant Fitzmorris, between 2010 to 2015, Diversicare unnecessarily placed beneficiaries in the highest category of reimbursement in order to receive higher payouts, and submitted forged pre-admission evaluation certifications to Medicaid.  As part of the settlement, Diversicare has entered into a Corporate Integrity Agreement for five years, Haggard will receive approximately $1.4 million, and Fitzmorris will receive approximately $145,450.  DOJ; USAO MDTN

February 19, 2020

Guardian Elder Care Holdings, Inc. has agreed to pay $15.5 million to settle claims of defrauding Medicare and Medicaid.  In a qui tam suit filed in 2015, whistleblowers Philippa Krauss and Julie White alleged that from 2011 to 2017, the Pennsylvania-based nursing home chain pressured its therapists to provide medically unnecessary rehabilitation to patients suffering from dementia or dying in hospice care in order to boost its profits.  During the subsequent government investigation, Guardian Elder Care self-disclosed that it had also billed federal healthcare programs for services performed by two excluded individuals.  As part of the settlement, Guardian Elder Care has entered into a chain-wide Corporate Integrity Agreement with the Department of Health and Human Services, and Krauss and White will split a $2.8 million relator's share.  USAO EDPA; USAO WDPA

Catch of the Week — Colorado Neurosurgeon and His Three Companies Settle Spinal Implant Kickback Claims for $2.35M

Posted  02/14/20
skeleton of a spine
This edition of our Catch of the Week series features the successful resolution of a whistleblower suit against neurosurgeon Dr. William Choi and three companies he owned.  The defendants agreed to pay the United States $2.35 million to resolve allegations that, for over five years, Dr. Choi received illegal kickbacks from spinal implant device distributors for devices he used in surgeries. The kickbacks rendered...

February 14, 2020

Tennessee-based Cookeville Regional Medical Center Authority (CRMC) has agreed to pay $4.1 million to settle allegations of violating the Anti-Kickback Statute, Stark Law, and False Claims Act from 2012 to 2017.  In a qui tam suit that initiated the investigation, an unnamed whistleblower alleged that CRMC submitted claims to Medicare and TennCare that arose from improper financial arrangements with physicians at its wholly owned subsidiary, CRMC MSO-Sub 1, Inc., d/b/a Tennessee Heart.  $3.6 million of the settlement proceeds will go to the United States, $453,000 will go to the State of Tennessee, and $779,000 will go to the whistleblower.  USAO MDTN
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