Medicaid

July 25, 2016

Florida announced the arrests of three individuals for operating a $1 billion Medicare and Medicaid fraud scheme involving numerous Miami-based health care providers. Attorney General Bondi’s MFCU, as part of the HEAT Strike Force, assisted in identifying more than $100 million of Medicaid fraud in connection to this scheme. According to the indictment, Philip Esformes, 47, operated a network of more than 30 skilled nursing homes and assisted living facilities that gave access to thousands of Medicare and Medicaid beneficiaries. Many of these beneficiaries did not qualify for skilled nursing home care or for placement in an assisted living facility. However, Esformes and co-conspirators admitted the beneficiaries to Esformes Network facilities, and received medically unnecessary services billed to Medicare and Medicaid. The defendants also allegedly received kickbacks by steering the beneficiaries to other health care providers, including community mental health centers and home health care providers, who also performed medically unnecessary treatments billed to Medicare and Medicaid. In order to hide the kickbacks from law enforcement, the kickbacks were often paid in cash, or were disguised as payments to charitable donations, payments for services and sham lease payments. FL

June 27, 2016

Ten North Texas companies and individuals agreed to pay $1.125 million to resolve charges they violated the False Claims Act for failing to comply with rules and regulations governing Medicaid transportation services.  The companies include: Irving Holdings, Inc. (together with its predecessor companies Big Tex Taxi Corporation, Terminal Taxi Corporation, Choice Cab, Inc., Yellow Checker Cab of Dallas, Inc., and Yellow Checker Cab of Fort Worth, Inc.); JetTaxi, Inc.; Dallas Taxi, LLC; US Cab, LLC; Terminal Taxi Corporation of Irving; Classic Shuttle Acquisition Corporation, Inc.; and Dallas Car Leasing, LLC.  The allegations originated in a whistleblower lawsuit filed under the qui tam provisions of the False Claims Act by Robert Spence, Mike Jones, and Cheryl Jones.  They were employees of Irving Holdings, one of the largest taxicab companies in the US.  They will receive a whistleblower award of $202,500 from the proceeds of the government's recovery.  DOJ (EDTX)

July 7, 2016

A Bedford-based transportation service provider has agreed to pay more than $700,000 to resolve allegations that it submitted false claims to the state’s Medicaid program (MassHealth) for medically unnecessary wheelchair van rides, Massachusetts announced. It also allegedly submitted claims for services that should have been provided at a lower cost through a MassHealth transportation broker. The AG’s investigation revealed that REM Transportation Services, LLC (REM) submitted the false claims from January 5, 2010 to December 31, 2014. Many of the MassHealth members allegedly receiving the rides were ambulatory and did not use wheelchairs or need assistance, as required under MassHealth regulations. MA

June 24, 2016

Florida arrested two Panama City mental health counselors for allegedly defrauding the Florida Medicaid program out of more than $360,000. The investigation revealed that Laurie Lynne Kidd, 54, who has a doctorate in psychology, hired Courtney Ann Hill, 27, to provide individual and group therapy to assisted living facilities. Hill is an unlicensed and unqualified employee and allegedly submitted false reports claiming that Hill provided therapy to the residents, when, in fact the defendant did not. Kidd billed Medicaid for the services never rendered as if Kidd herself performed the services. Kidd allegedly submitted more than $400,000 in fraudulent claims and received more than $360,000 from the Florida Medicaid program due to the fraudulent claims. Hill is allegedly responsible for $99,000 of Kidd’s fraudulent claims. FL

June 22, 2016

New York announced a $28 million settlement of a civil lawsuit that claimed the owners of Medford Multicare Center for Living, Inc. (“Medford”) located in Medford, New York looted the corporation and committed fraud and illegality in operating a business. The civil lawsuits claims were based on a history of criminal conduct by employees of the nursing home, staffing and service cuts and diversion of Medicaid funds to themselves and their controlled entities. The assurance of discontinuance provides that the settlement funds, which will be administered by an Independent Financial Monitor, will in part be used to establish a “Resident Care Fund” to fund care recommendations by the Independent Operator. That fund will provide the much needed reforms and improvements in the delivery of care and services to Medford’s elderly and frail residents. In addition, ten million dollars will be returned to the Medicaid program. The Medford corporation was also sentenced for its role in the cover-up of a patient death in 2012.‎ NY

June 20, 2016

New York announced the arrest of Joseph Wright, 52, of Middletown NY, for allegedly stealing over $5 million dollars from Medicaid. Prosecutors allege that Wright, as owner of a purportedly not-for-profit organization “Assistance By Improv II, Inc.” (ABI), located at 953 Southern Boulevard in the Bronx, lured thousands of low-income New Yorkers to ABI with the promise of affordable housing, arranged to have them subjected to unnecessary medical tests and then filed false claims for reimbursement with the State Medicaid program. Prosecutors alleged in papers filed in court that Wright unlawfully owns and operates ABI as a medical mill that masquerades as a charitable housing organization. Prosecutors allege that Wright ignored ABI’s professed charitable mission and duped potential clients, most of whom were Medicaid recipients, into surrendering their personal health care information and undergoing purported medical screening to qualify for housing. NY

June 1, 2016

Florence Bikundi and her husband Michael D. Bikundi Sr., owners of home care agency Global Healthcare Inc., were sentenced to prison for 10 years and 7 years, respectively, for health care fraud, money laundering, and other charges stemming from a scheme in which they and others defrauded the District of Columbia Medicaid program of over $80 million.  They were also ordered to forfeit over $11 million seized from 76 bank accounts; their $1 million residence; $73,000 in cash seized from their residence and five luxury vehicles.  The court also imposed a forfeiture money judgment of roughly $40 million and ordered them to pay roughly $80 million in restitution to D.C. Medicaid.  The government’s evidence showed the Bikundis led a scheme to bill Medicaid for services that were not fully provided, recruiting others, including family members, into the scam and creating fraudulent paperwork to hide the illegal activity.  DOJ

May 26, 2016

New York announced that it has entered into a settlement agreement with Vascuscript, Inc., d/b/a Mobile Pharmacy Solutions, to resolve allegations that it billed Medicaid for prescriptions which were written by an excluded Medicaid Provider. The Attorney General’s investigation determined that from April 21, 2010, through January 25, 2013, Vascuscript, Inc. submitted and received payment on approximately 4,600 claims to Medicaid for prescriptions that were written by Dr. Mikhail Strutsovskiy. The Department of Health had previously excluded Dr. Strutsovskiy from the Medicaid program, rendering prescriptions written by him ineligible for Medicaid reimbursement. Before filling a prescription, pharmacies are required under Medicaid billing rules to first ascertain whether the prescriber’s services are eligible for reimbursement. Because Vascuscript did not do so, it filled and delivered the prescriptions written by Dr. Strutsovskiy that were not eligible for Medicaid reimbursement. NY

May 13, 2016

A Somerville-based ambulance services provider has been sued for allegedly overbilling the state’s Medicaid program (MassHealth) for more than $600,000 in ambulance services that reflected a higher level of care than was actually provided. The complaint against Cataldo Ambulance Service, Inc. (Cataldo), filed on Thursday in Suffolk Superior Court, alleges that from 2005 to November 2015, Cataldo billed MassHealth for Emergency Advanced Life Support (ALS) services when, in fact, the patient’s condition at the scene only required, and the patient only received, Emergency Basic Life Support (BLS) services. Cataldo provides a variety of transportation services, including emergency ambulance services, throughout the Greater Boston area. According to the complaint, Cataldo’s inappropriate billing practices persisted despite being notified that, in many instances, the patient’s condition and the services rendered were insufficient to justify billing at an ALS level. MA

April 27, 2016

Pharmaceutical giants Wyeth and Pfizer, Inc. agreed to pay $784.6 million to resolve allegations that Wyeth violated the False Claims Act by reporting to the government false prices on two of its proton pump inhibitor (PPI) drugs, Protonix Oral and Protonix IV.  Under the state Medicaid programs, drug companies must provide Medicaid rebates based on the best prices they offer other customers.  According to the government, Wyeth hid from Medicaid bundled discounts it provided to thousands of hospitals across the country on Protonix Oral and Protonix IV.  By failing to report these bundled discounts, Wyeth allegedly avoided paying hundreds of millions of dollars in rebates.  The allegations originated in a whistleblower lawsuit filed under the qui tam provisions of the False Claims Act by Lauren Kieff, a former hospital sales representative for AstraZeneca and William St. John LaCorte, a physician practicing in New Orleans.  They will collectively receive a whistleblower award of roughly $98 million from the proceeds of the federal and state settlements.  Whistleblower Insider