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Private Insurance Whistleblower Reward Programs

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Healthcare Fraud also Harms Private Insurers - and Whistleblowers can Help

Posted  04/25/19
Health insurance forms, stethoscope, calculator and dollars
Whistleblowers with information about healthcare fraud look first to the False Claims Act, and the impact that healthcare fraud has on Medicare, Medicaid, and other government healthcare spending.  But, healthcare fraud that harms private insurance companies – as opposed to government payors – also attracts government enforcement attention.  Several recent criminal prosecutions in Texas and elsewhere illustrate...

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

Skyline Urology — Healthcare Fraud ($2.1M)

Constantine Cannon represented a whistleblower in a qui tam lawsuit that alleged that from 2013 through 2016 a large urology practice had fraudulently and systematically misused a billing code in order to increase reimbursements from insurers, including Medicare and private insurers in California. The code, modifier 25, is properly used when a physician performs an evaluation and management service and a separate and distinct service on the same day. Billing with modifier 25 when no distinct service occurred can improperly inflate reimbursement rates and is known as “unbundling fraud.” The Federal Government recovered $1.85M and the State of California recovered $250,000 to resolve the allegations. For his efforts in uncovering the fraud, the whistleblower received a portion of both recoveries. See The National Law Review and Becker’s ASC Review for more.

Healthcare Fraud: it’s not just Medicare and Medicaid

Posted  10/17/18
Last year, the U.S. Department of Justice recovered $2.4 billion in settlements and judgments involving fraud in the healthcare industry perpetrated against government payors. But government programs like Medicare and Medicaid aren’t the only targets of massive healthcare fraud schemes. A recent Department of Justice press release announced the unsealing of a 32-count indictment containing charges against four...

January 4, 2018

Kmart Corporation agreed to a $1 million settlement with the California Department of Insurance to resolve a whistleblower claim brought under the California Insurance Fraud Prevention Act.  KMart contracted with insurance companies to be reimbursed at a rate based on the company's charges to cash-paying customers, but was alleged to have submitted claims to private insurers in amounts that exceeded the agreed-upon rates.  CA

September 5, 2017

Novo Nordisk, Inc. has agreed to $1.1 million to resolve claims that its diabetes drug Victoza was unlawfully promoted for off-label use in violation of the California Insurance Frauds Prevention Act.  The claims were brought in a whistleblower action under that act filed by former Novo Nordisk researcher Peter Dastous, who will receive a share of the settlement.  CA

Fraudster of the Week -- Monarch Medical Group

Posted  04/28/17
Last week, California state prosecutors charged 26 individuals, including 21 physicians and 2 pharmacists, in connection with a kickback scheme orchestrated by Tanya and Christopher King, the owners of a practice management company called Monarch Medical Group and other related companies.   If convicted, the involved physicians could face up to 25 years in prison and the pharmacists could face up to 28 years. ...

DOJ intervenes in $50 Million Healthcare Fraud Case

Posted  03/2/17
By the C|C Whistleblower Lawyer Team Preet Bharara, US Attorney for the Southern District of New York, announced a civil suit and criminal actions against several doctors and health care entities alleging over $50M in fraud through schemes that lasted over 12 years. Five of the six doctors charged in their personal capacity were arrested in the New York area on Wednesday. The allegations center around Asim...

January 30, 2017

Florida announced a $1.5 million life claim settlement agreement reached with subsidiaries of the Ameriprise Group, RiverSource Life Insurance Company and RiverSource Life Insurance Company of New York. The settlement agreement focuses on the one-sided use of the Social Security Administration’s Death Master File to stop paying a deceased person’s annuity, but not using the same information to find and begin paying the deceased’s family or other beneficiaries for life insurance policies. Florida, California, New Hampshire, North Dakota and Pennsylvania conducted the examination into the companies that led to this agreement. Florida’s allocation of the multi-state settlement payment by Ameriprise is more than $111,000, which covers the costs of the investigations and future compliance monitoring. To date, state insurance regulators have either reached settlements or concluded the investigation of 28 of the top 40 companies constituting 80 percent of the total market. Efforts continue to be focused on the examination of the remaining 12 insurers. FL

November 21, 2016

Pennsylvania announced the filing of criminal charges against 50 individuals following investigations by the Office of Attorney General’s Insurance Fraud Section. The charges are part of a November sweep conducted by the Insurance Fraud Section, which is the largest law enforcement entity in Pennsylvania with specific authority to investigate and prosecute cases of insurance fraud. The total potential fraud involved in these cases is more than $1.1 million. The charges announced involve some of the most common types of insurance fraud. PA
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