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Other Government Health Programs

This archive displays posts tagged as relevant to government healthcare programs other than Medicare and Medicaid, and fraud in those programs. You may also be interested in our pages:

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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 15, 2019

Compounding pharmacy Midwest Compounders, Inc., and its owner Troy DeLong, agreed to pay $205,000 to resolve allegations that they submitted false claims to Tricare for prescriptions that resulted from unlawful arrangements between the pharmacy and prescribers or marketers, or otherwise overbilled for medically unnecessary dosages or redundant active ingredients.  The allegations were first made in a qui tam case filed by a whistleblower under the False Claims Act.  USAO ND Iowa

November 8, 2019

In the eleventh settlement involving the multi-state OK Compounding Pharmacy fraud scheme, podiatrist Jonathan Moore of Kentucky has agreed to pay $65,404 for the role he played in defrauding federal healthcare programs.  In exchange for illegal kickbacks disguised as “medical director fees,” Dr. Moore allegedly prescribed medically unnecessary compounded pain creams to patients, many of whom were insured by Medicare and TRICARE.  USAO NDOK

November 7, 2019

Compound drug ingredient supplier Fagron Holding USA LLC has agreed to pay over $22 million to resolve two qui tam suits involving three of Fagron’s wholly-owned subsidiaries.  According to whistleblowers, Freedom Pharmaceuticals Inc. grossly inflated the price of active pharmaceutical ingredients used in compound prescriptions, causing pharmacy customers to submit false claims to TRICARE.  Other allegations involved subsidiaries Pharmacy Services Inc. and B&B Pharmaceuticals Inc., which were accused of submitting false claims to federal healthcare programs, manipulating prescription drug pricing, paying kickbacks to physicians, and illegally waiving patient copays.  DOJ

October 31, 2019

In the largest healthcare fraud case ever to come out of Mississippi, pharmacy owner Thomas Spell has been sentenced to 10 years in prison and ordered to pay over $243 million in restitution for knowingly defrauding TRICARE.  Between 2014 and 2016, Spell and his co-conspirators had deviously marketed compounded medications based on their rate of reimbursement from TRICARE, paid illegal kickbacks to marketers in order to obtain prescriptions from TRICARE beneficiaries, and improperly waived mandatory copayments for TRICARE beneficiaries.  USAO SDMS

October 29, 2019

A former resident of Atlanta has been sentenced to 1.5 years in prison and ordered to pay $306,179 in restitution for defrauding PERACare, the Colorado Public Employees Retirement Association’s health insurance plan.  For more than two years, Michael Bang allegedly submitted fraudulent reimbursement claims involving three Atlanta-area pharmacies to Express Scripts, which administers PERACare’s prescription benefits. Altogether, his scheme netted him over $300,000.  USAO NDGA

CATCH OF THE WEEK — Ophthalmology group, former CEO, and individual physicians settle fraud claims for $6.65M

Posted  10/11/19
Our latest Catch of the Week highlights the successful resolution of a whistleblower lawsuit against a Southern California eye doctor group and several individuals allegedly embroiled in a decade-long scheme to bill publicly funded healthcare programs for unnecessary eye exams.  Ophthalmology provider group Retina Institute of California Medical Group (RIC), its former CEO, several of its doctors, and other involved...

September 26, 2019

Physician Philippe R. Chain will pay $300,000 to resolve allegations that he caused the submission of false claims to Tricare while working for telemedicine company CallMD. Chain allegedly issued and approved prescriptions for compounded medications, many of which were not medically necessary, without speaking to, examining, or otherwise having a physician-patient relationship with the patients.  USAO CT

September 18, 2019

Florida-based compounding pharmacy Diabetic Care Rx LLC, also known as Patient Care America, together with two of its executives, CEO Patrick Smith and VP of Operations Matthew Smith, and the private equity firm Riordan, Lewis & Haden Inc., will pay $21.36 million to resolve a case brought by two whistleblowers under the False Claims Act alleging that they paid unlawful kickbacks to secure referrals for patients covered by TRICARE, the federal healthcare program that covers military members and their families.  The pharmacy paid patient recruiters to target military members and their families for the prescription of compounded creams and vitamins formulated to ensure the highest possible reimbursement from TRICARE.  The marketers in turn paid doctors who issued the prescriptions, often without seeing or even speaking to the purported patients.  In addition, the pharmacy and marketing company often covered patient copayments through a sham charitable organization affiliated with the marketing company.  Private equity investor RLH was alleged to have known about and agreed to the kickback scheme.  Whistleblowers Marisela Medrano and Ada Lopez were, respectively, the former Director of Marketing and the Reimbursement Services Manager of PCA.  They will receive a yet-to-be-determined share of the U.S. recovery.  DOJ; SD FL

August 29, 2019

International SOS Assistance, Inc. and related entities and individuals have agreed to pay $940,000 to resolve claims that they overbilled TRICARE for air medical evacuation services provided to military service members and their families.  International SOS was alleged to have negotiated discounts from third-party air ambulance services, but failed to pass those discounts on to TRICARE.  The case was brought by a whistleblower who used to be a flight desk manager for International SOS; he will receive an award of $165,000.  USAO EDPA
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