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Medical Billing Fraud

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Sharp HealthCare — Medicare Fraud/Kickbacks (undisclosed settlement amount)

Three of our whistleblower attorneys represented a whistleblower in a qui tam action under the False Claims Act against Sharp HealthCare, a regional hospital system in San Diego.  Our client alleged that the Sharp Healthcare Center for Research, Sharp’s clinical-trial research arm, fraudulently billed government payers in violation of “secondary payer” rules that prohibit billing the government when other payers will pay for a patient’s care. Our whistleblower client also alleged that Sharp cultivated an illegal kickback scheme to entice prospective trial sponsors to host clinical trials at Sharp by regularly undervaluing Sharp’s costs involved in managing clinical trials.  By offering below-market value incentives and billing government and commercial insurers for injuries, the lawsuit alleged that Sharp sought to increase its attractiveness to trial sponsors. Sharp’s alleged purpose was to burnish the organization’s reputation and offer a lucrative stream of income for Sharp-affiliated physicians involved in clinical trials. Sharp settled the whistleblower’s case for an undisclosed amount.  Read more here.

November 22, 2019

Ave Maria Family Practice PLLC and its principal, Dr. Dorothy Agbafe-Mosley, have agreed to pay $1.25 million to the State of North Carolina to resolve claims that they falsely billed the state's Medicaid program for addiction treatment services allegedly provided to Medicaid beneficiaries.  In fact, the services were not medically necessary, had no supporting clinical documentation, or were otherwise performed in violation of Medicaid policy.  NC

Government Audit of Chronic Care Management Services Raises Serious Questions About Proposed Anti-Kickback Statute Safe Harbors

Posted  11/22/19
stethoscope on top of money and coins
The U.S. Department of Health and Human Services is engaged in what it calls a “Regulatory Sprint to Coordinated Care,” in order to, in the words of HHS Deputy Secretary Eric Hargan, “update, reform, and cut back our regulations to allow innovation toward a more affordable, higher quality, value-based healthcare system.”  On October 9, 2019, as part of this effort to “cut back” on regulations to advance...

November 20, 2019

Louisville, Kentucky hospital Jewish Hospital & St. Mary’s Healthcare Inc. has agreed to pay $10.1 million to resolve allegations that the hospital, doing business as Pharmacy Plus and Pharmacy Plus Specialty, submitted false claims to Medicare for prescription drugs that did not have the required physician order or proof of delivery, for prescription refills that were not reasonable and necessary, or for prescriptions that otherwise did not meet Medicare coverage requirements.  In addition, defendant was alleged to have violated the Anti-Kickback Statute by providing unlawful remuneration to patients in the form of free blood glucose testing supplies and waiver of co-payments and deductibles for insulin.  The case was initiated by a qui tam complaint filed by pharmacist Robert Stone, who will receive $1.85 million from the settlement.  DOJ

November 19, 2019

Clinical laboratory LabTox, LLC, will pay $2.1 million to resolve claims that it falsely billed Medicare and Kentucky's Medicaid program for qualitative urine drug screens as high complexity screens when, in fact, LabTox performed only low complexity testing, and wrongfully billed Medicare for un-covered specimen validity testing.  USAO ED KY

November 15, 2019

California healthcare system Sutter Health, its hospital the Sutter Memorial Center Sacramento, and the Sacramento Cardiovascular Surgeons Medical Group, Inc., will pay a total of $43.12 million to resolve allegations that the entities violated the Stark Law and improperly double-billed Medicare.  Specifically, Sutter Memorial will pay $30.5 million to resolve charges of wrongfully billing Medicare for services referred to the hospital by Sac Cardio, with whom the hospital maintained improper financial arrangements that overcompensated the Sac Cardio physicians.  In addition, Sutter will pay $15.12 million to resolve allegations that it paid physicians compensation at rates that exceeded fair market value, leased office space to them at below-market rates, and reimbursed them for expenses at inflated rates.  In addition to the Stark Law violations, the settlement also resolved allegations that Sac Cardio submitted duplicative bills for physician assistant services (Sac Cardio will pay $500,000 to resolve these claims), and allegations that several Sutter ambulatory surgical centers had double-billed Medicare for radiological services that had actually been provided, and billed for, by a separate entity.  DOJ reported that allegations against Sutter Memorial and Sac Cardio were first made in a qui tam lawsuit brought by Laurie Hanvey, who will receive $5.9 million from the settlement, and that Sutter Health self-disclosed other conduct at issue in the settlement. DOJ; USAO ED Cal; USAO ND Cal

November 14, 2019

Following a guilty plea in 2018, Sandra Haar was sentenced to five years in prison and has agreed to sell 13 properties, including former clinic properties, to resolve civil claims under the False Claims Act that she and the non-profit provider of health and dental services she ran, Horisons Unlimited, submitted fraudulent claims to Medi-Cal, including claims for services rendered by unlicensed providers, claims for services that were not rendered at all, and claims for unnecessary services. Haar was also alleged to have received thousands in kickbacks from a laboratory in exchange for sending Horisons patients to the lab. Haar will be excluded from Medicare participation for 20 years; the former Horisons CFO, Norman Haar, will be excluded for 15 years.  USAO ED Cal

November 13, 2019

Vibra Healthcare, LLC and related entities, which operate freestanding acute medical rehabilitation hospitals and long term acute care hospitals nationwide, will pay $6.25 million to resolve allegations that Highlands Rehabilitation Hospital in El Paso, Texas, which was operated by Vibra, submitted false claims to Medicare.  Specifically, Vibra was alleged to have billed for services that did not meet conditions of payment, including requirements that inpatient rehabilitation facilities provide an intensive level of services to patients.  The case was initiated by a qui tam complaint filed by Thomas A. FlorenUSAO WDTex

November 13, 2019

The Louisiana Department of Health, which manages Louisiana’s Medicaid program, will pay $13.42 million to the federal government to resolve allegations that the state submitted false claims for federal share reimbursement of state Medicaid expenditures for long-term nursing care and hospice care.  The federal government alleged that in anticipation of a reduction in federal payments for such services, the state agency directed its healthcare contractor, Molina Medical Solutions, to pre-bill for nursing home and hospice services in order to receive funds at the existing higher rates.   DOJ

CATCH OF THE WEEK — Sanford Health to pay over $20M for kickback, unnecessary spinal surgery claims brought by two Sanford doctors

Posted  10/30/19
skeletal drawing of spine
Our Catch of the Week features a $20.25 million settlement with South Dakota-based Sanford Health, Sanford Medical Center, and Sanford Clinic announced by the Justice Department in an October 28, 2019 press release.  The settlement resolves allegations the massive health system knowingly submitted claims for medically unnecessary spinal surgeries and tainted by kickbacks to a top Sanford neurosurgeon.  Two Sanford...
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