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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 29, 2020

Medtronic has agreed to pay over $9.2 million to resolve allegations of violating the False Claims Act and CMS’s Open Payments Program by paying kickbacks to a South Dakota-based neurosurgeon, Wilson Asfora, M.D., in order to induce sales of its SynchroMed II implantable intrathecal infusion pumps.  According to the government, Medtronic allegedly sponsored nine years’ worth of events at a restaurant owned by Asfora, and to which Asfora would invite his acquaintances, business partners, trusted colleagues, and referral sources.  For his role in the kickback scheme, Asfora has been named in a separate FCA lawsuit, which the United States joined last November.  USAO SD

Constantine Cannon Settles Case Alleging Kickbacks to Multi-Practice Physicians’ Group for Referrals to Wholly Owned Ambulatory Surgery Center – Whistleblower Was Former CEO

Posted  10/9/20
doctor operating with nurse
Constantine Cannon, on behalf of whistleblower Jeffery Neuberger, has settled a False Claims Act action against Mid Dakota Clinic and a related entity.  Mr. Neuberger, the former CEO of the medical group, filed his case in 2017 alleging a scheme in violation of the Anti-Kickback Statute (AKS) between the medical group and its wholly owned ambulatory surgery center (ASC).  At issue was a financial arrangement whereby...

Mid Dakota Clinic – Medicare Fraud/ASC Kickbacks ($5.45M)

The Constantine Cannon team represented Jeffery Neuberger, the former CEO of a medical group in North Dakota, in a 2017 False Claims Act case alleging a scheme in violation of the Anti-Kickback Statute (AKS) between the medical group and its wholly owned ambulatory surgery center (ASC).  The AKS is intended to prevent abuses (such as unnecessary treatments) that can occur when a doctor makes money from referring patients for goods or services.  The ASC safe-harbor to the AKS is limited; it essentially permits ASC ownership only by surgeons who perform procedures or surgeries in the ASC as a functional extension of his or her office.  The lawsuit alleges that all of the multi-practice physician owners profited from referrals, not only the surgeons, and that they refused to give up this lucrative income stream despite knowing that it violated the AKS.  In November 2019, Mid Dakota Clinic, its affiliated building partnership, and insurer agreed to pay the United States $4.15 million to resolve the case.  The clinic additionally paid $1.3 million for the whistleblower’s attorneys’ fees and costs, for a total payment of $5.45 million.  The United States awarded Mr. Neuberger a 25% relator’s share of its recovery.

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 23, 2020

Gilead Sciences, Inc. has agreed to pay $97 million to resolve claims of paying kickbacks to Medicare beneficiaries in connection with its pulmonary arterial hypertension drug, Letairis.  From 2007 to 2010, Gilead enticed beneficiaries to purchase Letairis by allegedly referring the beneficiaries to a foundation, Caring Voice Coalition (CVC), and then making payments to CVC to cover patient copays of Letairis specifically, in violation of the Anti-Kickback Statute and Medicare rules.  Additionally, Gilead routinely obtained data from CVC that it used to inform future payments, including how many CVC clients were on Letairis, how much CVC spent on those clients, and how much CVC expected to spend on them in the future.  DOJ; USAO MA

September 9, 2020

West Virginia-based acute care hospital, Wheeling Hospital, Inc., has agreed to pay $50 million to resolve claims of violating the Anti-Kickback Statute, Physician Self-Referral (Stark) Law, and False Claims Act.  According to a former executive turned whistleblower, Louis Longo, Wheeling knowingly provided referring physicians with compensation above fair market value, based on the volume or value of their referrals, then submitted claims resulting from those improper referrals to Medicare.  As part of the settlement, Longo will receive a $10 million relator’s share.  DOJ; USAO WDPA; USAO NDWV

September 3, 2020

Two affiliates of Independence Blue Cross, Keystone Health Plan East, Inc. and QCC Insurance Company, Inc., which offer Part C Medicare Advantage plans, agreed to pay $2.25 million to resolve allegations that they overstated their costs when they submitted bids to CMS for contract years 2009 and 2010.  As a result, CMS reimbursed them at at an inflated rate.  The matter was initiated by the filing a qui tam complaint under the False Claims act by Eric Johnson, who will receive $500,000 from the recovery.  USAO EDPA
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