Upcoding Archives - Page 4 of 11

Integra Med Analytics Loses Battle to Establish New Breed of Corporate Whistleblower Outsiders, Write Mary Inman and Max Voldman in RACMonitor

Posted 06/10/20

attorney headshots of Mary Inman and Max Voldman

Constantine Cannon whistleblower attorneys Mary Inman and Max Voldman updated their earlier reporting in RAC Monitor regarding the False Claims Act case brought by Integra Med Analytics against Texas-based hospital chain Baylor Scott & White. At the end of May, the Fifth Circuit Court of Appeals upheld a Texas district court opinion dismissing the case. As we have earlier written, Integra alleged that the...

Tagged in: CC Lawyers, FCA Federal, Healthcare Fraud, Hospital Fraud, Medical Billing Fraud, Public Disclosure and Public Information, Upcoding, Whistleblower Eligibility,

Data Analysts: a New Kind of Whistleblower to “Catch a Rogue,” write Gordon Schnell and Max Voldman in Stat News

Posted 03/20/20

On March 16, 2019, STAT published an article by Constantine Cannon whistleblower lawyers Gordon Schnell and Max Voldman about a new kind of whistleblower emerging: the data-driven whistleblower. The article, Data analysts: a new kind of whistleblower to ‘catch a rogue’?, discusses different courts’ reaction to False Claims Act cases brought by Integra Med Analytics, a “forensic analysis firm that studies...

Tagged in: CC Lawyers, FCA Federal, Healthcare Fraud, Public Disclosure and Public Information, Upcoding,

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

Tagged in: FCA Federal, Healthcare Fraud, Medical Billing Fraud, Medical Devices and DME, Medicare, Other Government Health Programs, Provider Fraud, Upcoding, Whistleblower Case,

October 29, 2019

Encompass Health Corporation (EHC), f/k/a HealthSouth Corporation, has agreed to pay $4 million to resolve of improperly billing Medicare. According to the DOJ, between 2008 and 2012, an inpatient rehabilitation facility owned by EHC had improperly assigned low Functional Independence Measure scores on Patient Assessment Instrument forms in a bid to receive higher reimbursements from Medicare. USAO NV

Tagged in: FCA Federal, Healthcare Fraud, Medical Billing Fraud, Medicare, Provider Fraud, Upcoding,

October 4, 2019

Southern California-based Retina Institute of California Medical Group (RIC), its former CEO, and several of its physicians have agreed to pay the State of California and United States $6.65 million to settle alleged violations of state and federal False Claims Acts. According to former administrators Bobbette Smith and Susan Rogers, between 2006 and 2017, the ophthalmology group improperly billed Medicare and Medicaid for unnecessary and unperformed eye exams, upcoded simple exams using codes normally reserved for emergency conditions, and waived mandatory co-payments and deductibles to induce patient referrals. Smith and Rogers will receive a relator’s share, which remains to be determined. USAO CDCA

Tagged in: FCA Federal, FCA State, Healthcare Fraud, Lack of Medical Necessity, Medicaid, Medical Billing Fraud, Medicare, Provider Fraud, Upcoding, Whistleblower Case,

July 24, 2019

Pennsylvania-based Eagleville Hospital has agreed to pay $2.85 million to settle allegations of defrauding Medicare, Medicaid, and the Federal Employees Health Benefits Program. According to an anonymous relator, Eagleville violated the False Claims Act between 2011 and 2018 by submitting claims for substance abuse patients improperly admitted for high paying, hospital-level detoxification treatments. The whistleblower will receive $500,000 of the recovery. USAO EDPA

Tagged in: FCA Federal, Healthcare Fraud, Hospital Fraud, Medicaid, Medicare, Other Government Health Programs, Upcoding, Whistleblower Case, Whistleblower Rewards,

Question of the Week — Should providers who defraud Medicare be excluded from it?

Posted 06/18/19

Fortune Cookie with Message with Message Saying "Not Eligible for Medicare!"

Sometimes, though rarely, when a medical provider settles a False Claims Act case or is found to have violated the FCA at trial, they are excluded from participating in healthcare programs as a condition of resolving the case. Often, this is a limited-time ban that is meant to incentivize providers to follow Medicare’s rules in the future and to deter other providers from committing fraud. Between Medicare,...

Tagged in: FCA Federal, Medical Billing Fraud, Medicare, Question of the Week, Upcoding,

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 million. USAO NDIL

Tagged in: FCA Federal, Healthcare Fraud, Medicare, SNF, Upcoding, Whistleblower Case,

May 31, 2019

Oklahoma Heart Hospital, LLC and Oklahoma Heart Hospital South, LLC (collectively “OHH”), have agreed to pay $2.8 million to resolve a qui tam suit by a former employee, which alleged that OHH violated the federal and state False Claims Acts and defrauded Medicaid by submitting claims for outpatient procedures as if they were inpatient procedures. Though multiple allegations were raised in the lawsuit, only the allegation involving the upcoded claims was intervened by the government; the other allegations will be dismissed as part of the settlement. USAO WDOK

Tagged in: FCA Federal, FCA State, Healthcare Fraud, Hospital Fraud, Medicaid, Upcoding, Whistleblower Case,

May 9, 2019

Carolina Physical Therapy and Sports Medicine, Inc. agreed to pay $790,000 to settle a whistleblower lawsuit alleging the company knowingly submitted false claims to Medicare and TRICARE. According to former employee Hilary Moore, Carolina PT submitted claims for group physical therapy services that were billed as though they were one-on-one sessions. Additionally, claims for certain services performed by physical therapy assistants were billed as though they were performed under the supervision of qualified therapists. For exposing the fraudulent conduct, Moore will receive a relator’s share of $142,200. USAO SC

Tagged in: FCA Federal, Healthcare Fraud, Improper Medical Personnel, Provider Fraud, Upcoding, Whistleblower Case, Whistleblower Rewards,

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