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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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August 31, 2020

Brooklyn, New York resident Aleksander Pikus was sentenced to 13 years in prison and ordered to pay $39.4 million in restitution and forfeit $2.6 million following his conviction at trial for charges related to a kickback and tax avoidance scheme involving a number of medical clinics in Brooklyn and Queens.  Pikus referred patients to the clinics, receiving kickbacks in exchange, which he used to pay patient recruiters and patients themselves.  Pikus used shell companies and fake invoices to conceal his scheme and failed to report cash income to the IRS.  DOJ; USAO ED NY

August 21, 2020

Cardiologist Ghanshyam Bhambhani of Queens, New York, paid $2 million to settle allegations that he paid kickbacks to fellow physicians for patient referrals.  Specifically, defendant was alleged to have paid other doctors compensation disguised as rent for patient referrals in violation of the Anti-Kickback Statute and the False Claims Act, and falsified records to justify cardiac procedures.  The action was initiated by the filing of a whistleblower complaint.  USAO ED NY

Windfall to Health Insurers Due to COVID-19 Is Not Yet Resulting in Resolution of FCA Risk Adjustment Cases

Posted  08/21/20
By Edward Baker
As health insurers book record profits during the COVID-19 pandemic due to a dramatic decline in elective surgeries and procedures, this seems like a good time to ask about the status of False Claims Act litigation against Medicare Advantage Organizations (MAOs) relating to risk adjustment fraud.  Given the dire shortfall in state and federal money to fight the pandemic, when will MAOs begin paying back the billions...

August 21, 2020

A Georgia-based chiropractor and her medical practice have been ordered to pay more than $5 million for violating the False Claims Act.  The government alleged that Dr. Jennifer Heller, D.C. caused Medicare to pay $1.4 million more than it would have had it known that hundreds of Heller’s charges for a surgical neurostimulator procedure were in actuality for acupuncture devices, which are not covered by Medicare, and which do not require surgery.  To resolve the charges, Heller Family Medicine, LLC will have to pay $4.3 million, while Heller herself will have to pay $700,000.  USAO SDGA

Whistleblowers Are Critical to Exposing Fraud in the Murky World of For-Profit and Private-Equity Nursing Home Operations

Posted  07/17/20
By Jessica T. Moore
person following a trail of money
The settlement of a fraud case against 27 skilled nursing facilities controlled by private owners demonstrates “the power of whistleblowers to shine a light on improper business practices and obtain significant recoveries on behalf of United States taxpayers.”  (U.S. Attorney Nick Hanna, C.D. California.)  The government’s recognition of the contributions of whistleblowers in the False Claims Act case against...

June 30, 2020

Ophthalmic Consultants, P.A. and its principal Robert K. Snyder have agreed to pay $4.8 million to resolve claims that they unlawfully billed federal healthcare programs for the drugs ranibizumab (Lucentis®) and aflipercept (Eylea®).  While the drugs are sold in single-use vials, defendants used single vials to provide doses to multiple patients, allowing them to obtain excessive reimbursement from Medicare, TRICARE, and the Federal Employees Health Benefits Program.  USAO MD FL

Under Cover of Pandemic, Nursing Home Residents Illegally Evicted

Posted  06/26/20
By Jessica T. Moore
wheelchair in the hospital lobby
“It felt opportunistic, where some homes were basically seizing the moment when everyone is looking the other way to move people out.”  (Laurie Facciarossa Brewer, long-term care ombudsman in New Jersey).  With nursing homes involved in more than 40% of coronavirus deaths, in depth reporting by Jessica Silver-Greenberg and Amy Julia Harris at the New York Times reveals a new threat to residents’ care and...

Medicare Risk Adjustment Fraud is Not Victimless

Posted  06/18/20
By Edward Baker
medicare dollars
Implicit in the arguments made by many Medicare Advantage Organizations (MAOs), health plans, hospital networks and other defendants in response to whistleblower and government False Claims Act complaints is that the alleged misconduct—falsifying diagnosis data so that CMS overpays for patients enrolled in an MA plan—involves just a technical record-keeping or administrative dispute with CMS and no actual...

Increased Federal Funds, Incentives, and Requirements for Nursing Homes Brings Worrisome Opportunities for Fraud

Posted  06/5/20
By Jessica T. Moore
wheelchair in the hospital lobby
The pandemic has exposed the razor thin margin for error by which our most vulnerable are cared for in nursing homes. New aggregate federal data reveal the appalling toll on facility residents and staff: over 31,700 deaths as of June 4, 2020 (an undercounted 1/3 of all US COVID-19 deaths), according to the federal government’s Nursing Home Compare.  Responsive federal funding for nursing homes, requirements for...

Private Equity Ownership of Nursing Homes Might Have Made Everything Worse

Posted  05/15/20
By Jessica T. Moore
person pocketing money in a business suit
Most nursing homes already had no room for error before COVID-19.  Years of private equity ownership and competition with other elder-care services dealt a one-two punch to the cash-strapped facilities’ ability to react to the pandemic crisis, says The New York Times in a troubling analysis.  In particular, private equity firms’ relentless quest for profits, miniscule margins, and regular cash-draining...
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