Medical Billing Fraud

March 14, 2019

The former owner and former COO of Atlanta-based Primera Medical Group, Shailesh Kothari and Timothy McMenamin, were sentenced to prison terms of 6.75 and 7.75 years, respectively, for their roles in submitting more than $8.5 million in fraudulent invoices to private insurance companies for allergy testing and allergy immunotherapy services that were never provided and were not medically necessary.  Defendants submitted bills using the NPIs of doctors who had not performed the tests and, in fact, had no knowledge of the services.  To cover up the fact that the services were not provided, defendants would create false laboratory reports for insurers and patients who requested them.  USAO ND GA

March 13, 2019

Following an earlier guilty plea, Waveney Blackman, the owner of Washington, D.C. durable medical equipment company WaveCare Health Services, was sentenced to 3.5 years in prison for her role in submitting nearly $10 million in fraudulent claims to Medicaid for would care products that were not actually purchased and provided.  Blackman was also ordered to forfeit $9.4 million and pay restitution in the same amount.  DOJ; USAO DC

February 25, 2019

Skyline Urology will pay $1.85 million to resolve allegations under the federal False Claims Act that it improperly billed Medicare for evaluation and management (E&M) services that did not meet the criteria for separate billing.  Skyline allegedly used "Modifier 25" to unbundle its E&M billing even when the E&M services were provided on the same day as other billed medical services and were not significant, separately identifiable, and beyond those ordinarily involved with the associated procedure.  A whistleblower, James M. Cesare, filed a qui tam complaint, and will receive a relator's share of approximately $323,750.  DOJ

February 22, 2019

Marketers, doctors, lawyers, and medical service provider defendants were sentenced this week for their roles in a multi-million dollar California worker's compensation fraud scheme in the San Diego area.  The defendants recruited patients and referred them to co-defendant attorneys to file fraudulent claims on their behalf and medical providers who performed often unnecessary and painful medical procedures for which they would then bill insurers including California Workers' Compensation.  Ronald Grusd, a doctor who owned a diagnostic imaging company, was sentenced to 10 years in prison and ordered to forfeit $1.3 million.  Fermin Iglesias, who worked as a patient capper, was sentenced to 5 years in prison and ordered to forfeit $1 million. Julian Garcia, who provided services to assist the referrals and kickbacks, was sentenced to three years in prison.  Jennifer Louise White, who marketed to providers in the network, was sentenced to two years in prison.  Sean O'Keefe, an attorney who filed fraudulent claims on behalf of patients, was sentenced to 13 months in prison and ordered to forfeit $300,000.  Steven Rigler, a chiropractor, was sentenced to six months in prison.  USAO SD Cal.

February 22, 2019

The owner of New York Pharmacy, Inc., NYC Pharmacy Inc., and NY Healthfirst Pharmacy Inc., pharmacist Hin T. Wong, has pleaded guilty to criminal charges arising from millions of dollars in false billing to New York's Medicaid program for HIV drugs.  Wong billed Medicaid for medications that she never dispensed, a scheme disclosed by an investigation confirming that Wong's pharmacies did not purchase a sufficient inventory of medication from licensed drug wholesalers to account for the quantity of medication for which Wong’s pharmacies billed Medicaid and Medicaid Managed Care Organizations.  In addition, Wong paid kickbacks to individuals to bill for medications that were not, in fact, dispensed.  Under a related civil settlement, Wong will surrender over $3.6 million to the state.  NY

February 21, 2019

Hooshang Poor, a doctor of geriatric medicine based in Newton, Massachusetts, has agreed to pay $680,000 to resolve claims under the False Claims Act that he knowingly submitted inflated charges to Medicare and the Massachusetts Medicaid program.  Dr. Poor was alleged to submit bills with false procedural codes that overstated the length, extent, and scope of services that he furnished to nursing home residents, and misrepresented services provided by non-physician employees.  USAO Mass.

February 19, 2019

Xerox Corporation will pay $236 million to the State of Texas to resolve claims that the company and its subsidiary Conduent, which provided services to the Texas Medicaid program, improperly approved requests for orthodontic procedures without ensuring that the procedures met Medicaid program requirements.  As a result, the state paid for orthodontic work that was unnecessary or did not meet program requirements.  Texas

February 13, 2019

Ashraf Hasan-Hafez and Ilya Kogan have been sentenced to over three years in prison for their participation in a scheme that defrauded Medicare and New York State Medicaid out of $1.3M dollars. Hasan-Hafez, the owner of a physical therapy practice, and Kogan, the owner of an acupuncture company, fraudulently submitted bills for services that were not rendered, or for services performed by unlicensed individuals. In addition to jail time, Hasan-Hafez and Kogan have been ordered to forfeit $1,297,000 in restitution to the Medicare and Medicaid programs.  DOJ