Medical Billing Fraud Archives - Page 3 of 52

August 11, 2022

Spivack, Inc., formerly operating as Verree Pharmacy, and owner-pharmacist Mitchell Spivack, have agreed to pay over $4.1 million in civil penalties for dispensing opioids despite numerous red flags the drugs were being diverted—all in violation of the False Claims Act and the Controlled Substances Act. In furtherance of the fraud, Spivack made false statements to drug distributors to maintain the façade of legitimacy, while concurrently drawing millions from the pharmacy and harming the public. In addition to their opioid fraud, Spivack and Verree effectuated their “Bill But Don’t Fill” scheme, where they would enter “BBDF” in their internal computer system, and would submit false claims to insurers for drugs not actually dispensed. USAO EDPA

Tagged in: FCA Federal, Healthcare Fraud, Lack of Medical Necessity, Medical Billing Fraud, Pharma Fraud,

August 5, 2022

Gonzaga Interventional Pain Management, Melvin Gonzaga, M.D., and his son Rommel Gonzaga will pay $980,000 for violating the False Claims Act by submitting claims for medically unnecessary urine drug tests. GIPM required patients to submit a UDT sample before being seen by a provider and discussing the results from any prior UDT the patient received. Regardless of the patients’ individualized testing needs, GIPM always opted for the more complex “definitive” UDT rather than the lower-level “presumptive” UDT, netting a higher reimbursement rate from the US government. USAO MD

Tagged in: FCA Federal, Lack of Medical Necessity, Medical Billing Fraud, Medicare, Provider Fraud, Upcoding,

August 3, 2022

North Country Neurology, P.C. will pay $850,000 for violating the False Claims Act by submitting claims falsely listing a physician as the service provider, when the services were provided instead by an unsupervised non-physician practitioner. Medicare will reimburse for certain services provided by NPPs, but require a physician to be physically present in the office and immediately available to furnish assistance. This was not the case on over 120 occasions, and NCN admitted it should have known it was improper to bill at the higher physician rather than NPP level. Additionally, NCN improperly billed Medicare on approximately 761 occasions for Botox, even though it had already been paid for by another insurer. NCN blamed their insufficient compliance program for the errors. USAO NDNY

Tagged in: FCA Federal, Healthcare Fraud, Improper Medical Personnel, Medical Billing Fraud, Medicare, Provider Fraud, Upcoding,

July 29, 2022

Old Man’s Home of Philadelphia d/b/a Saunders House, a skilled nursing facility, will pay $819,640 for its violations of the False Claims Act. A whistleblower filed suit under the qui tam provisions of the FCA, alleging Saunders House overbilled federal healthcare programs for therapy services provided; billed for therapy services not provided; billed for unreasonable, unnecessary, and sometimes harmful therapy; and manipulated clinical services to maximize billing. Medicare Part A paid Saunders House based on beneficiaries’ assigned Resource Utilization Group, and Saunders billed at the highest RUG level—Ultra High or RU—despite the lack of reasonableness or necessity for the patients. USAO EDPA

Tagged in: FCA Federal, Healthcare Fraud, Medical Billing Fraud, Medicare, Provider Fraud, SNF, Upcoding, Whistleblower Case,

June 6, 2022

SNAP Diagnostics LLC, along with its founder, Gil Raviv, and vice president, Stephen Burton, will pay a combined $3.925 million to settle allegations of False Claims Act and Anti-Kickback Statute violations. SNAP routinely submitted claims for Medicare and TRICARE patients’ second and third nights of home sleep testing, when patients with private health insurance were routinely billed only for the first night. Additionally, SNAP multiplied copays from senior citizen Medicare beneficiaries, and incentivized physicians to refer their patients for sleep testing services. USAO NDIL

Tagged in: Anti-Kickback and Stark, FCA Federal, Healthcare Fraud, Laboratory and IDTF, Medical Billing Fraud, Medicare, Other Government Health Programs, Provider Fraud,

June 3, 2022

Rodney L. Yentzer will pay $900,000 for violating the False Claims Act. Through Pain Medicine of York, a group of clinics he controlled, Yentzer caused the submission of false claims for payment to Medicare for urine drug tests that were not medically reasonable or necessary and were not used to aid in the diagnosis and treatment of patients. He is excluded from participation in all federal health care programs for 22 years. In March of 2022, Yentzer pleaded guilty to Health Care Fraud, Money Laundering, and Theft of Public Money for defrauding Medicare, Medicaid, and the U.S. Department of Health and Human Services between 2016 and 2020. USAO MDPA

Tagged in: FCA Federal, Healthcare Fraud, Laboratory and IDTF, Lack of Medical Necessity, Medicaid, Medical Billing Fraud, Medicare, Other Government Health Programs, Provider Fraud,

June 2, 2022

Middle Georgia Family Rehab (MGFR) has been ordered to pay $9.6 million in damages after a judge for the Middle District of Georgia found the facility had fraudulently billed TRICARE and Medicaid. In an April order granting partial summary judgment, the Court determined that approximately 800 claims submitted to federal healthcare programs were billed under therapists who were not employed at MGFR at the time of alleged service. USAO MDGA

Tagged in: FCA Federal, Healthcare Fraud, Medicaid, Medical Billing Fraud, Other Government Health Programs,

June 1, 2022

Caris Life Sciences, Inc. will pay $2.9 million to resolve claims that it falsely billed Medicare for laboratory tests to detect the activity of certain genes within a tumor that predicted the risk of recurrence by fraudulently circumventing Medicare’s 14-day rule, which, during the relevant time period, prohibited laboratories from separately billing Medicare for tests performed on specimens if a physician ordered the test within 14 days of the patient’s discharge from a hospital stay. By submitting separate claims for the laboratory tests, Medicare paid twice for the same service, first to the hospital as part of the hospital’s lump-sum DRG payment, and in a direct payment to Caris. Caris allegedly discouraged providers from ordering testing within 14 days of discharge, or canceled and re-submitted orders to avoid the 14 day window. The settlement covers two separate whistleblower actions. USAO EDNY

Tagged in: Anonymity, FCA Federal, Healthcare Fraud, Laboratory and IDTF, Medical Billing Fraud, Whistleblower Case,

May 19, 2022

Healthcare testing company VirtuOx, Inc. agreed to pay $3.15 million to resolve claims brought in an action initiated by a whistleblower alleging that falsely billed Medicare for pulse oximetry testing. VirtuOx allegedly reported San Francisco as the location for overnight pulse oximetry testing when, in fact, no services were performed at that location, but that location resulted in a higher Medicare reimbursement. In addition, VirtuOx allegedly billed Medicare for both oxygen “spot checks” and overnight pulse oximetry testing, when only the overnight testing was performed. The whistleblower, Amber Watt, will receive an award of $630,000. USAO SD FL

Tagged in: Bundling and Unbundling, FCA Federal, Healthcare Fraud, Laboratory and IDTF, Medical Billing Fraud, Whistleblower Case, Whistleblower Rewards,

May 16, 2022

Oklahoma Heart Hospital South, LLC paid over $1.1 million to settle alleged violations of the False Claims Act. An OHHS internal review and audit exposed Medicare billing irregularities related to their Intensive Cardiac Rehabilitation services, which they self-disclosed to the government. The US government’s follow-up investigation, with which OHHS cooperated, revealed that for a 6-year period—from 2013 to 2019—OHHS physicians failed to complete and update patients’ individualized treatment plans for care that lasted longer than 30 days. The settlement is not an admission of OHHS’ liability, and the government did not concede any of its claims. WDOK USAO

Tagged in: FCA Federal, Healthcare Fraud, Medical Billing Fraud, Medicare, Provider Fraud,

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