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Medical Billing Fraud

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Constantine Cannon settles with one defendant in case alleging bilking of the Medicare Advantage program. Kaiser Foundation Health Plan of Washington (formerly Group Health Cooperative) will pay $6.375M.

Posted  11/17/20
health insurance forms with stethoscope and calculator
Teresa Ross, a whistleblower represented by Constantine Cannon, and the Department of Justice have reached a settlement with Kaiser Foundation Health Plan of Washington (formerly Group Health Cooperative or GHC).  The Medicare Advantage Organization (MAO) has agreed to pay $6.375 million to resolve allegations that the insurance plan improperly collected money from the Medicare Advantage program by overstating how...

Group Health Cooperative (now a subsidiary of Kaiser Permanente) – Medicare Advantage Fraud ($6.375 million)

Constantine Cannon represents whistleblower Teresa Ross against Group Health Cooperative, an insurance company that participates in the Medicare Advantage program. GHC has agreed to pay $6.375 million to resolve allegations that the insurance plan improperly collected money from the Medicare Advantage program by overstating how sick its beneficiaries were. Ms. Ross is a former employee of GHC, where she worked for 14 years; her most recent position was the director of risk adjustment services. In her complaint, Ms. Ross alleged that GHC had improperly relied on coders’ interpretations of diagnostic tests, prescriptions, and entries in problem lists to come up with diagnoses and that it had also submitted other codes that were false because they were diagnosed by inappropriate providers, fell outside service year, or the patient had no evidence of a current condition. See Press Release and Whistleblower Insider for more.

November 16, 2020

Seattle’s Group Health Cooperative, now part of Kaiser, will pay $6.375 million to settle allegations in a whistleblower suit that it falsely reported unsupported diagnosis codes to Medicare in order to receive inflated payments.  The suit alleges that GHC utilized the services of a coding review company, DxID, that proposed unsupported diagnosis codes, which GHC knowingly submitted to CMS as part of seeking higher payment for the affected Medicare Advantage beneficiaries.  Whistleblower Teresa Ross, represented by Constantine Cannon, will receive approximately $1.5 million.  DOJ

October 22, 2020

Jerry Taylor of North Carolina has been sentenced to five years in prison and ordered to pay more than $6.1 million in restitution for his role in a $9.4 million fraud scheme targeting North Carolina’s Medicaid program.  Along with his brother Tony and co-conspirators in Ohio and New York, Taylor submitted claims for behavioral health services benefiting local at-risk youth that were purportedly performed at companies he owned and operated with his brother, but that were in reality not actually performed or misrepresented in the claims.  In addition to defrauding Medicaid, Taylor also evaded taxes by failing to report more than $1.6 million in reimbursements in 2016 and 2017.  For those charges, Taylor will pay over $346,000 to the IRS.  USAO WDNC

Catch of the Week: 345 Charged in $6 Billion National Health Care Fraud and Opioid Takedown

Posted  10/2/20
Paper Ripped Uncovering Medical Necessity Wording
In the largest health care fraud and opioid enforcement action in the Justice Department’s history, 345 defendants—including more than 100 doctors, nurses, and other medical professionals—face charges for submitting over $6 billion in false or fraudulent claims to federal and private insurers.  Defendants stand accused of submitting $4.5 billion in fraudulent claims linked to telemedicine, $845 million...

October 2, 2020

Two New York-based physical therapy providers have agreed to pay $4 million to resolve whistleblower-brought allegations of violating the False Claims Act by improperly billing multiple government healthcare programs, including Medicare, Medicaid, the Federal Employees’ Compensation Act Program (FECA), and the Federal Employees’ Health Benefits Program (FEHBP).  The alleged misconduct by Williamsburg Physical Therapy, P.C., Euro Physical Therapy, P.C., owners Alex and Diana Klurfeld, and management company First Plus Services, Inc. occurred between 2008 to 2018, and involved billing for physical therapy services provided or supervised by someone other than the licensed therapist listed on claims, as well as backdating services after treatment authorizations had expired.  USAO EDNY

September 29, 2020

Laredo optometrist David Mora will pay $3.23 million and enter into a corporate integrity agreement to resolve claims that he submitted false claims to Medicare between 2013 and 2019.  Mora allegedly billed for services including punctal plug insertion, sensorimotor testing, vision therapy, and amniotic membrane placement, where the patient’s condition did not warrant the service as medically necessary or reasonable.  USAO SD TX

September 22, 2020

New Jersey biotechnology company Bio-Reference Laboratories, Inc., will pay $11.5 million to resolve two actions brought by whistleblowers alleging that defendant violated the Anti-Kickback statute by paying unlawful remuneration to physicians based on the volume of those doctors’ referrals to defendant.  The remuneration took the form of payments for a percentage of the cost of electronic medical records software used by the doctors.  In addition, defendant was alleged to have unlawfully billed Medicare and Tricare for testing performed on hospital inpatients, instead of billing the hospitals themselves.  USAO SDNY

September 21, 2020

Neurosurgical Care LLC, its medical director Sagi Kuznits, and its practice director Pnina Kuznits, will pay over $1 million to resolve claims that they overbilled Medicare, TRICARE, and the Federal Employees Health Benefits Program, for the implantation of neuro-stimulators.  Defendants improperly billed the non-surgical application of P-Stim and Stivax devices as surgical procedures, and improperly billed for the application of an eVox device which was not approved for Medicare reimbursement.  USAO ED PA

September 10, 2020

Shreveport Prosthetics, Inc. will pay $1.6 million to resolve claims in an action brought by the company’s former office administrator, Kimberly Throgmorton, under the qui tam provisions of the False Claims Act.  The company was alleged to have submitted false bills to Medicare by using the supplier number of a different company after its own supplier number was deactivated, and by routinely waiving patient co-payments.  Ms. Throgmorton will receive over $250,000 as a whistleblower reward.  USAO WD LA
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