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June 28, 2019

The nation’s largest operator of inpatient rehabilitation facilities (IRFs) has agreed to pay $48 million to settle allegations that it violated the False Claims Act.  Three separate lawsuits filed by former contract physician Dr. Emese Simon, former director of therapy operations Melissa Higgins, and former medical director Dr. Darius Clarke, alleged a number of Encompass Health Corporation, f/k/a HealthSouth Corporation IDFs, falsely diagnosed patients with “disuse myopathy” and improperly admitted patients too sick or disabled to participate in physical therapy in order to earn higher reimbursements from Medicare.  The whistleblowers’ collective share of the settlement is $12.4 million.  DOJ; USAO MDFL

June 11, 2019

A physical therapy center, its owner, and four nursing facilities in the Chicago area have settled an intervened qui tam suit that alleged that they upcoded patient Resource Utilization Group (RUG) scores, in violation of the False Claims Act, in order to increase Medicare payments.  Quality Therapy & Consultation Inc and owner Francise Parise allegedly worked in conjunction with Carlton at the Lake Inc, Ridgeview Rehab and Nursing Center, Lake Shore Healthcare and Rehabilitation Centre LLC, and Balmoral Home Inc to manipulate the RUG scores, which indicate the level of skilled nursing care each patient requires.  By upcoding the scores, the defendants allegedly claimed higher reimbursement rates from Medicare.  As part of the settlement, each of the facilities will pay between $1 and $4 million, and Parise will pay $160,000, for a combined recovery of $9.7 millionUSAO NDIL

Default by Nursing Home Chain on HUD-Guaranteed Mortgage Highlights Potential for Fraud in Section 232 Program

Posted  06/3/19
Nursing Home with Elderly People
Last week, the New York Times reported on the collapse of Rosewood Care Centers, a chain of nursing homes with facilities in Illinois and Missouri. According to the report, the chain had faced years of operational and financial difficulties, including fines by state regulators, personal injury claims by residents, and lawsuits by investors and vendors. When it went under, Rosewood defaulted on $146 million in...

April 5, 2019

Philip Esformes of Miami Beach, Florida, was found guilty of crimes arising from his role in the submission of over $1.3 billion in fraudulent claims to Medicare and Medicaid.  According to evidence introduced at trial, between 1998 and 2016, Esformes, who owned a network of assisted living and skilled nursing facilities, bribed physicians to admit patients into his facilities, which were in poor condition and unable to provide adequate treatment. Patients often failed to receive appropriate medical services, or received medically unnecessary services.  Esformes was later sentenced to 20 years in prison. USAO SD FL

February 27, 2019

Tennessee-based skilled nursing facility chain Vanguard Healthcare LLC, along with former executives William Orand and Mark Miller, have agreed to pay upward of $18 million to resolve False Claims allegations of billing Medicare and Medicaid for worthless and "grossly substandard nursing home services." According to press releases, five facilities in the Vanguard network allegedly submitted false claims for reimbursement, despite a litany of failures, including forging nurse and physician signatures, using unnecessary physical restraints on residents, failing to prevent pressure ulcers, failing to provide wound care as ordered, failing to provide standard infection control, failing to administer medications as prescribed, and failing to meet basic nutrition and hygiene requirements. The case is considered the largest case of fraud involving worthless services in state history. DOJ; USAO MDTN

February 5, 2019

Tennessee Health Management, Inc (THM) has agreed to pay over $9.7 million to settle fraud allegations, with over $5 million going to the United States and over $4 million going to the State of Tennessee. From 2010 to 2017, the skilled nursing facility management company allegedly submitted claims with false physician certifications to the state's Medicaid Program, TennCare, in violation of TennCare's rules as well as the False Claims Act. As part of the settlement, THM has also agreed to sign a Corporate Integrity Agreement. USAO MDTN

January 28, 2019

A skilled nursing facility based in Orlando, Florida, Conway Lakes NC, LLC, and related entities and physicians, have agreed to pay $1.5 million to resolve allegations that they engaged in a unlawful kickback and referral scheme for Medicare and TRICARE beneficiaries.  Conway Lakes was alleged to have contracted with orthopedic surgeon Kenneth Krumins under a sham “medical director” arrangement in violation of the Stark Law and Anti-Kickback Statute to induce him to refer patients for rehabilitation services.  A former employee of Conway Lakes, Jonathan Montes de Oca, reported the arrangement by filing a qui tam case under the False Claims Act and will receive $267,000 of the proceeds.  USAO MDFL

August 23, 2018

Reliant Rehabilitation Holdings Inc has agreed to pay $6.1 million to settle claims brought on by whistleblower Dr. Thomas Prose that it paid kickbacks to doctors and nursing homes to promote its business and filed reimbursement claims arising from improper contracts — both violations of the False Claims Act. Under the settlement agreement, Dr. Prose will receive a relator’s share of $915,000. DOJ

August 15, 2018

Post Acute Medical, LLC has agreed to pay $13,031,502 to the United States, $114,016 to Texas, and $22,482 to Louisiana to settle allegations brought on by whistleblower Douglas Johnson that it violated the Anti-Kickback Statute, Physician Self-Referral Law, and state and federal False Claims Acts. The operator of long-term care and rehabilitation hospitals nationwide was accused of cultivating "reciprocal referral relationships" with outside healthcare providers and then billing Medicare and Medicaid for services that arose from those relationships. For his role in exposing the alleged fraud, Johnson will receive a cut of the federal government's share totaling $2,345,670. DOJ

July 18, 2018

Two consulting companies and nine nursing homes will pay $10M to resolve allegations that they submitted claims for medically unnecessary rehabilitation services to Medicare. Medicare reimburses nursing homes based on Resource Utilization Group (RUG) levels, which are supposed to determine the amount of skilled therapy required by a patient. The government alleges that the nursing homes, as advised by the consulting companies, encouraged medically unreasonable and unnecessary therapy to inflate RUG levels. The case was filed by three whistleblower, who will receive a total award of $2M. DOJ
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