Medicaid
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November 2, 2018
Metropolitan Retina Associates, Inc. and its owner, Dr. Kenneth S. Felder, have settled a False Claims Act investigation by agreeing to pay $2,064,559 for Medicare and Medicaid fraud. As part of the settlement, the New York-based ophthalmology practice admitted and accepted responsibility for submitting claims involving medically unnecessary and improperly documented fluorescein angiograms, as well as ultrasounds of the eye. USAO SDNYOctober 31, 2018
A London-based doctor has been sentenced to 42 months in federal prison for defrauding Medicare, Medicaid, and private insurers. The doctor, Dr. Anis Chalhoub, was convicted in April of implanting over 200 medically unnecessary pacemakers in patients at St. Joseph London hospital, reportedly even pressuring patients and giving them misleading information so that they would agree to the procedures. He is ordered to pay $257,515 in restitution to Medicare, Medicaid, and private insurers, as well as a $50,000 fine. USAO EDKYOctober 30, 2018
Four people connected to a Texas-based home health agency have been found guilty of fraudulently obtaining $3.7 million in reimbursements from Medicare and Medicaid. Despite being previously banned from participating in any federal healthcare reimbursement programs, Celestine Okwilagwe and Paul Emordi co-owned and operated a Medicare and Medicaid provider in the Dallas area called Elder Care. Adetutu Etti, the provider's administrator, was recruited to falsely certify that someone else was the owner, and Okwilagwe's wife, Loveth Isidaehomen, was recruited to sign checks. Some of the claims that were eventually reimbursed by Medicare were also found to be for services that were not medically necessary. DOJOctober 25, 2018
Passavant Memorial Homes and its pharmacy subsidiaries have agreed to pay $1,850,000 to resolve allegations that it billed federal healthcare programs, including Medicare and Medicaid, for improperly prescribed controlled substances, in violation of the False Claims Act and Controlled Substances Act. While the controlled substances were prescribed for a legitimate medical purpose, they were not deemed valid with only a doctor's order by Medicare and Medicaid rules. The company later self-disclosed to the government and has since changed its policy to comply with these rules. USAO EDPA; USAO WDPAOctober 24, 2018
The owners and operators of two community mental health clinics in Pennsylvania and North Carolina have entered into a $3 million consent judgment with the United States to resolve allegations of violating the False Claims Act. In 2000, Melchor Martinez was convicted of Medicaid fraud by the State of Pennsylvania and subsequently banned from owning and operating health clinics or seeking reimbursement from all federally funded healthcare programs. Despite this, he allegedly continued to own and operate three chains of mental health clinics—including Northeast Community Health Centers, Lehigh Valley Community Mental Health Centers, and Carolina Community Mental Health Centers—by enlisting the help of his wife, Melissa Chlebowski, to act as the true owner and operator. In addition, the two allegedly failed to operate according to rules set by Medicare and Medicaid, including seeing patients for only 2-3 minutes and billing for 15, and billing for services provided by unqualified staff. They were eventually outed in a qui tam lawsuit filed by a former employee. USAO EDPAOctober 22, 2018
A Kentucky-based medical equipment supplier has agreed to pay $5,254,912 to settle claims based on the False Claims Act that it defrauded many government insurers, including Kentucky Medicaid, Medicare, and CHAMPVA (under the Department of Veterans Affairs), by submitting fraudulent claims relating to certain compounded creams that it produced. According to the DOJ press release, in order to be properly reimbursed, Cooley Medical Equipment, Inc. was required to obtain prior authorization from Kentucky Medicaid and CHAMPVA before using certain powdered ingredients. Instead, Cooley claimed to use cream-based versions of the same ingredients, then submitted thousands of false claims to the insurers, and received millions of dollars in reimbursements. The company eventually came clean and self-disclosed to the US Attorney's Office, allowing it to pay a fine of 1.5 times instead of the usual 3 times loss suffered by the government. USAO EDKYOctober 16, 2018
A Medicaid transportation provider, its president, and a driver have been sentenced to pay a $10,000 fine and serve 2-4 years in prison for stealing a total of $1.2 million from New York's Medicaid program. The driver who was sentenced, Haimid Thompson, was accused of paying a Medicaid recipient to enroll in services from his employer and submitting falsified logs showing daily trips on behalf of the recipient. He was ordered to pay $23,598. The company, 716 Transportation, Inc., was sentenced to a fine of $10,000, and the president, Wossen Ambaye was ordered to pay restitution of $900,497, for knowing the services billed were not actually provided. NY AGSeptember 26, 2018
A psychologist, John R. Sink, and his wife, Diane Sink, pled guilty to making false statements to Wyoming Medicaid. According to the plea, between 2012 and 2016, the Sinks submitted over $6.2 million in claims for group therapy, knowing that the activities provided and billed for did not qualify as group therapy. In addition, the hours billed did not accurately report the time each Medicaid beneficiary was actively participating in any activities, and the Sinks were not using up-to-date treatment plans to guide each Medicaid beneficiaries treatment as required by Wyoming Medicaid. USAO D. Wy.Third Circuit Clarifies the Public Disclosure Bar in United States ex rel. Silver v. PharMerica
Posted 09/7/18
Whistleblower Marc Silver secured a victory from the Third Circuit on September 4, 2018, which held that his action was not blocked by the “public disclosure bar” of the False Claims Act, reversing a lower court that had dismissed his action. The Third Circuit’s opinion appropriately recognizes that a whistleblower can use non-public information as a bridge between public information and allegations of fraud,...