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Medical Billing Fraud

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June 20, 2019

Hart to Heart Ambulance Services, d/b/a Hart to Heart Transportation Services, has agreed to pay $1.25 million to settle allegations that it defrauded Medicare by submitting claims for medically unnecessary services, violating the False Claims Act.  Allegations were first brought to the government’s attention by former employee, Bryan Arvey, who alleged that from 2010 to 2017, Hart to Heart management pressured employees to falsify claims for non-emergency ambulance transports, such as hospital discharges.  For aiding in the recovery of public funds, Arvey will receive a share of $251,000.  USAO MD

Question of the Week — Should providers who defraud Medicare be excluded from it?

Posted  06/18/19
Fortune Cookie with Message with Message Saying "Not Eligible for Medicare!"
Sometimes, though rarely, when a medical provider settles a False Claims Act case or is found to have violated the FCA at trial, they are excluded from participating in healthcare programs as a condition of resolving the case. Often, this is a limited-time ban that is meant to incentivize providers to follow Medicare’s rules in the future and to deter other providers from committing fraud. Between Medicare,...

May 17, 2019

Dr. Donald Douglas, the physician owner of three healthcare clinics in Texas, has agreed to pay $118,000 to resolve allegations of improperly billing Medicare at the physician rate for services performed by advance practice nurses (“APNs”) without direct physician supervision.  Under Texas law, APN-provided services performed with physician supervision may be billed to Medicare at the full physician rate.  USAO EDTX

May 9, 2019

Paul J. Mathieu and Hatem Behiry were found guilty for their part in a $30 million scheme to defraud Medicare and the New York State Medicaid program. Between 2007 and 2013, Mathieu falsely posed as an owner of three medical clinics (the “Clinics”) in Brooklyn. During that time, the Clinics fraudulently billed Medicare and Medicaid for medical services and supplies that were not necessary, or were not even provided. Furthermore, Mathieu did not see any patients at that time. Instead, he falsified large stacks of bogus medical records in which he stated that he did see and treat those patients. Behiry, a physical therapy doctor, also participated in the Clinic’s fraudulent billing practices by pretending to provide physical therapy services to patients. Mathieu and Behiry have not yet been sentenced. DOJ

May 8, 2019

Tea Kaganovich and Ramazi Mitaishvili, co-owners of New York Diagnostic Testing Centers, each pleaded guilty to health care fraud and conspiracy to defraud the lawful functions of the Internal Revenue Service (IRS). The couple submitted false health care claims for diagnostic testing services and paid over $18 million in kickbacks for the referral of beneficiaries who signed up for diagnostic testing and other alleged medical services. They fraudulently reported to the IRS that the illegal kickback payments were valid business expenses, thus causing relevant tax forms to under-report business income and claim deductions. DOJ

May 6, 2019

Acadia Healthcare Company, Inc., which operates outpatient drug treatment centers in West Virginia through its subsidiary CRC Health, L.L.C., will pay $17 million to resolve claims that it improperly billed the state's Medicaid program for urine and blood testing services as if they had performed the testing themselves, despite the fact that Acadia lacked the certification to perform the tests.  In fact, the testing was performed by an independent outside laboratory, and that lab independently billed Medicaid for the tests, at a lower rate. Medicaid paid Acadia’s treatment centers $8,500,000 for the improperly-billed tests.  As part of this settlement, defendants also entered into a five-year corporate integrity agreement to maintain specified compliance programs and procedures.  USAO SDWV

May 3, 2019

Dr. Richard E. Paulus, an Ashland cardiologist, was sentenced to five years in prison for defrauding Medicare, Medicaid, and private insurers. Evidence showed that Paulus implanted medically unnecessary stents in his patients and falsified the degree of stenosis in their medical records. He has been charged with one count of health care fraud and ten counts of making false statements in regard to health care matters. In addition to time in prison, Paulus must also pay $1.1 million in restitution to Medicare, Medicaid, and other private insurers who were also victims of his financial scheme. DOJ

May 2, 2019

Chimes Delaware, which provides services to individuals with developmental disabilities in Delaware, will return $4.5 million in Medicaid funding to the state to resolve claims of billing errors in its supported employment programs and transportation services.  Chimes also agreed to institute new internal controls and billing procedures.  DE

April 30, 2019

Home healthcare company Avenue Homecare Services, Inc, of Dracut, Massachusetts, will pay $8.3 million to resolve allegations that between 2013 and 2016 it defrauded the state's Medicaid program, MassHealth, by submitting false bills for unauthorized services not supported by a valid plan of care from a physician.  In some cases, Avenue submitted bills for home healthcare services for patients who were hospitalized at the time of the alleged services.  The settlement also requires the company to implement a compliance program to continue as a MassHealth provider.  MassAG
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