Court says that fraudsters who violate rules they later claim are unclear may not violate the False Claims Act
Posted 08/19/21
Medicaid
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August 17, 2021
Bristol Myers Squibb (BMS) has agreed to pay $75 million to a resolve a whistleblower’s allegations that it underpaid drug rebates owed to state Medicaid programs nationwide. In order to ensure states pay competitive prices, federal law requires pharmaceutical companies to return a portion of payments from state Medicaid programs, calculated based on the average price paid by drug wholesalers. The misconduct involved BMS underreporting their drugs’ Average Manufacturer’s Price by treating wholesaler fees as discounts, thus decreasing the amount it supposedly owed to the healthcare programs. CA AG; NJ AGJuly 23, 2021
Alabama non-profit SpectraCare Health Systems, Inc., which provides services including developmental disability services, intermediate care medical services, and behavioral health services, agreed to pay $1 million to resolve claims first brought in a whistleblower action alleging that the provider improperly billed Alabama Medicaid and failed to return overpayments to the Alabama Medicaid Agency. The defendant was alleged to have submitted false claims including claims without correct and complete documentation, and duplicate claims, and to have knowingly retained payments it received to which it was not entitled. The settlement will be split between the federal government and the Alabama Medicaid Agency, with the whistleblower receiving 19% of the federal recovery. USAO MD ALJuly 22, 2021
Medical laboratory Bluewater Toxicology, LLC, agreed to pay $1.2 million following its self-report of overbilling for urine drug testing services. In billing Medicare, Kentucky Medicaid, Indiana Medicaid, TRICARE, and CHAMPVA, Bluewater was alleged to have submitted false claims that misrepresented the number of drugs tested in definitive urine drug tests, that lacked sufficient documentation, or that were for specimen validity testing that is not separately billable to Medicare. USAO ED KYJuly 19, 2021
Prime Healthcare Services, one of the largest hospital systems in the nation, its founder and CEO Dr. Prem Reddy, and interventional cardiologist Dr. Siva Arunasalam have agreed to pay $37.5 million to resolve two suits filed by former executive Martin Mansukhani, and former employees Marsha Arnold and Joseph Hill. In violation of the federal and California False Claims Acts, certain Prime hospitals had allegedly submitted inflated invoices to Medi-Cal and other government health programs, or submitted claims to Medi-Cal and Medicare under Arunasalam’s provider number for services provided by an excluded physician. Additionally, in acquiring Arunasalam’s physician practice and surgery center, Prime allegedly paid above fair market value for referrals from Arunasalam to one of their hospitals. For being the first to file, one of the whistleblowers, Mansukhani, will receive a relator’s share of nearly $10 million. CA AG; USAO CDCAJuly 2, 2021
An Ohio-based hospital system that has since been acquired by the Cleveland Clinic Foundation has agreed to pay over $21 million to resolve alleged violations of the Anti-Kickback Statute, Physician Self-Referral Law, and False Claims Act. Between 2010 and 2016, Akron General Health System (AGHS) allegedly paid area physician groups far above fair market value in order to induce referrals, then submitted claims arising from those illegal referrals to federal healthcare programs. The settlement resolves a qui tam suit brought forth by former internal audit director at AGHS, Beverly Brouse, and Ethical Solutions LLC. DOJJune 25, 2021
Connecticut Addiction Medicine, LLC (CAM) and its owners, Dr. Jay Benson and Dr. Mahboob Aslam, have agreed to pay over $1 million to resolve their liability under the False Claims Act in connection with overcharges for urine drug tests that they caused to Medicare and Medicaid. As part of their standard practice, CAM ran presumptive tests in-house but also sent the same sample out to an independent reference laboratory for definitive tests. CAM then billed federal healthcare programs for the medically unnecessary presumptive tests. USAO CTJune 23, 2021
El Paso Ear, Nose & Throat Associates (EPENT) has agreed to pay $750,000 to settle allegations of defrauding Medicaid, Medicare, and TRICARE. In violation of the False Claims Act, EPENT allegedly billed the programs at a higher rate of reimbursement than what they were actually entitled to by upcoding evaluation and management codes. USAO WDTXJune 14, 2021
Centene Corp. will pay a total of $143.8 million to resolve claims by Ohio and Mississippi that it overbilled the states' Medicaid programs in its role as a pharmacy benefit manager. The states alleged that Centene engaged in practices including "spread pricing," charging more than allowed price caps based on industry standards, inflation of dispensing fees, failure to disclose discounts received, and claiming reimbursement for prescriptions already paid for by third parties. Ohio will receive $88.3 million, and Mississippi will receive $55.5 million. OH; MSCatch of the Week: Dental Clinics to Pay $2.7M for Using Unsterilized Tools on Medicaid Patients
Posted 05/28/21
