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Provider Fraud

This archive displays posts tagged as relevant to fraud by healthcare providers. You may also be interested in our pages:

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January 15, 2020

TMJ & Orofacial Pain Treatment Centers of Wisconsin has agreed to pay $1 million to settle a qui tam suit alleging submissions of false claims to Medicare and TRICARE.  According to the anonymous whistleblower, who will receive an undisclosed share of the settlement, TMJ billed the government health programs for prosthetic devices as if they had been fabricated by in-house surgeons, when in fact they had been fabricated by an outside laboratory.  USAO EDWI

January 7, 2020

Behavioral Consulting of Tampa Bay (BCOTB) has agreed to pay $675,000 to settle claims alleging the autism service provider submitted false or fraudulent claims to TRICARE.  Following an audit by TRICARE's managed care support contractor, the United States launched an investigation into BCOTB's claims that revealed it had misrepresented the services that were provided, misrepresented the identity of service providers, requested payment on more units of time than reflected by records, and requested payment on services that were not substantiated by records.  USAO MDFL

January 6, 2020

A now defunct behavioral health clinic, Tree of Life, Inc., and its owners and operators, Ada and Victor Vidal, have agreed to pay $1.65 million to settle a whistleblower's claims that they violated the False Claims Act and Anti-Kickback Statute in claims to Pennsylvania's Medicaid program.  According to Erika Desjardins, the former Clinical Director, Tree of Life billed for therapy sessions where either the patient or therapist could not possibly have attended (in some cases due to a patient’s hospitalization or death), as well as therapy sessions provided by unqualified individuals.  To facilitate the fraud scheme, it created fake records, including forged signatures, and improperly paid a social worker for patient referrals.  As part of the settlement, the Vidals have been excluded from future participation in federal healthcare programs, and Desjardins, who had been fired for reporting internally, will receive $330,000 as their share of the recovery.  USAO EDPA

January 2, 2020

Two physicians in the San Diego area have agreed to pay nearly $1 million to settle allegations that they violated the False Claims Act by improperly billing Medicare for care provided by an uncredentialed physician.  The fraudulent conduct by Drs. Mark Smith and Fane Robinson of San Diego Retina Associates was revealed in a qui tam lawsuit by fellow ophthalmologist and former partner, Dr. Atul Jain, who will receive $170,778 of the settlement proceeds.  USAO SDCA

December 19, 2019

Nassir Medical Corp., which does business as the Cancer Care Institute, and its owner, Dr. Youram Nassir, have agreed to pay $3.4 million to resolve allegations that they violated the False Claims Act by billing Medicare and Medicaid for oncology drugs that were not actually purchased, dispensed, or administered, and for infusion services that were not actually provided.  The case was initiated by whistleblower Kenneth Bryan, who will receive a whistleblower reward of $475,000 from the federal government.  USAO CD Cal

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.

December 10, 2019

Dr. Paul J. Mathieu and occupational therapist Lina Zhitnik have been sentenced to, respectively, 4 years and 1.2 years in prison, for their roles in a $30 million scheme to defraud Medicare and New York's Medicaid program.  Mathieu falsely posed as the owner of three medical clinics, which were actually owned by Aleksandr Burman, and Mathieu and Zhitnik falsely claimed to have treated thousands of patients at those clinics.  Over six years, Mathieu prepared or assisted in the preparation of false and fraudulent medical charts, issued referrals for expensive and unnecessary additional testing by providers also participating in the scheme, and wrote prescriptions for unnecessary medical supplies that were filled by a company also owned by Burman.  Another doctor participating in Burman's scheme, Ewald J. Antoine, was previously sentenced.  USAO SDNY

November 22, 2019

Ave Maria Family Practice PLLC and its principal, Dr. Dorothy Agbafe-Mosley, have agreed to pay $1.25 million to the State of North Carolina to resolve claims that they falsely billed the state's Medicaid program for addiction treatment services allegedly provided to Medicaid beneficiaries.  In fact, the services were not medically necessary, had no supporting clinical documentation, or were otherwise performed in violation of Medicaid policy.  NC

November 15, 2019

California healthcare system Sutter Health, its hospital the Sutter Memorial Center Sacramento, and the Sacramento Cardiovascular Surgeons Medical Group, Inc., will pay a total of $43.12 million to resolve allegations that the entities violated the Stark Law and improperly double-billed Medicare.  Specifically, Sutter Memorial will pay $30.5 million to resolve charges of wrongfully billing Medicare for services referred to the hospital by Sac Cardio, with whom the hospital maintained improper financial arrangements that overcompensated the Sac Cardio physicians.  In addition, Sutter will pay $15.12 million to resolve allegations that it paid physicians compensation at rates that exceeded fair market value, leased office space to them at below-market rates, and reimbursed them for expenses at inflated rates.  In addition to the Stark Law violations, the settlement also resolved allegations that Sac Cardio submitted duplicative bills for physician assistant services (Sac Cardio will pay $500,000 to resolve these claims), and allegations that several Sutter ambulatory surgical centers had double-billed Medicare for radiological services that had actually been provided, and billed for, by a separate entity.  DOJ reported that allegations against Sutter Memorial and Sac Cardio were first made in a qui tam lawsuit brought by Laurie Hanvey, who will receive $5.9 million from the settlement, and that Sutter Health self-disclosed other conduct at issue in the settlement. DOJ; USAO ED Cal; USAO ND Cal

November 14, 2019

Following a guilty plea in 2018, Sandra Haar was sentenced to five years in prison and has agreed to sell 13 properties, including former clinic properties, to resolve civil claims under the False Claims Act that she and the non-profit provider of health and dental services she ran, Horisons Unlimited, submitted fraudulent claims to Medi-Cal, including claims for services rendered by unlicensed providers, claims for services that were not rendered at all, and claims for unnecessary services. Haar was also alleged to have received thousands in kickbacks from a laboratory in exchange for sending Horisons patients to the lab. Haar will be excluded from Medicare participation for 20 years; the former Horisons CFO, Norman Haar, will be excluded for 15 years.  USAO ED Cal
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