Upcoding
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December 7, 2021
New Jersey-based Princeton Pathology Services P.A. will pay $2.4 million to resolve allegations that it overbilled Medicare by submitting claims using a Current Procedural Terminology (CPT) code that required written analysis by a pathologist, when no such analysis was required or had been prepared. A whistleblower, Jayant Barai, M.D., initiated the matter by filing a qui tam complaint under the False Claims Act, and will receive an award of $456,000. USAO NJSutter Health – Healthcare Fraud/Medicare Advantage ($90 million)
Constantine Cannon represented a whistleblower in a False Claims Act case alleging Sutter Health and its affiliates inflated the number and severity of Medicare Advantage patient diagnoses, manipulated patient records, ignored audit red flags, and engaged in other misconduct to increase patient risk scores and obtain Medicare Advantage payments to which they were not entitled. In August 2021, Sutter agreed to pay $90 million to settle the matter, the largest Medicare Advantage False Claims Act settlement to date against a hospital system, and at the time, the second largest reported Medicare Advantage fraud settlement ever. Our client received a whistleblower award of roughly $22 million. Read more -- AP, Reuters, SF Chronicle, DOJ, PR Newswire, CC.August 30, 2021
Northern California healthcare provider Sutter Health and its affiliated entities will pay $90 million to resolve a False Claims Act case initially filed by whistleblower Kathy Ormsby alleging that defendants submitted unsupported diagnosis codes for patients enrolled in Medicare Advantage. Sutter contracts with Medicare Advantage Organizations to provide care to Medicare Advantage beneficiaries enrolled in their plans, and allegedly caused those MAOs to submit to Medicare inaccurate and invalid diagnosis codes that inflated the risk scores of those beneficiaries and were not supported by the medical records, thereby resulting in overpayments by CMS. Sutter also allegedly failed to take sufficient corrective action when it became aware of the submission of these unsupported diagnosis codes. Sutter also entered into a five-year corporate integrity agreement. Sutter previously entered into a partial settlement of $30 million, which will be credited against the $90 million total settlement. DOJ; USAO ND CalAugust 25, 2021
Georgia-based psychotherapy provide Carenow Services, LLC, together with its CEO Leena Karun, will pay $2 million to resolve allegations of FCA violations through their billing for services at nursing homes that were not medically necessary, that were improperly documented, and at higher intensity levels than justified. The investigation was initiated when a former Carenow employee filed a qui tam complaint; the whistleblower will receive an undisclosed whistleblower reward. USAO ND GaMedia Coverage of Government Intervention in Kaiser Medicare Advantage Suits: LA Times says Cases Point to a “Massive Fraud Problem in Medicare”
Posted 08/6/21
United States Reaches a “Tipping Point” in Managed Care Enforcement: DOJ Intervenes in Constantine Cannon’s Lawsuit Against Kaiser Permanente
Posted 07/30/21
