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Upcoding

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Catch of the Week -- Prime Healthcare

Posted  08/9/18
upcoding
Prime Healthcare, a nationwide healthcare provider that operates 45 hospitals and employs over 40,000 people, has settled allegations under the False Claims Act that 14 of its California hospitals improperly billed Medicare for admitting patients who only required outpatient care, and billed Medicare for treating more severe diagnoses than patients actually had. The company will pay just under $62 million to settle...

August 3, 2018

Prime Healthcare Services and related entities, as well as its CEO Dr. Prem Reddy, will pay $65 million to settle two Medicare fraud allegations. First, Prime and Dr. Reddy allegedly engaged in a centralized scheme to boost inpatient admissions of patients who had no medical need to be admitted. Second, they allegedly falsely upcoded patients’ diagnoses in order to increase reimbursements. Whistleblower Karin Berntsen, who initiated the lawsuit, will receive over $17 million of the settlement. DOJ; CDCA

July 10, 2018

Liberty Ambulance agreed to pay $1.2 million to settle an FCA qui tam alleging that, from 2005 to 2016, Liberty had fraudulently upcoded life support services and unnecessarily transported patients.  The case was filed by whistleblower Shawn Pelletier, who will receive $264,000 from the settlement, on top of $1.2 million he had received from prior settlements with other defendants.  USAO MDFL

Catch of the Week -- Health Quest Systems and Putnam Hospital Center

Posted  07/13/18
This week, DOJ announced a $14.7 million settlement with NY-based Health Quest Systems, Inc. (Health Quest), and its subsidiary hospital Putnam Health Center (Putnam) based on their submission of inflated and otherwise impermissible claims for payment to Medicare and Medicaid, making Health Quest and Putnam our Catch of the Week. The settlement resolves allegations stemming from three separate lawsuits bought by...

June 29, 2018

Preferred Care Inc. and its related skilled nursing facility and owner agreed to pay $540,000 to resolve allegations under the False Claims Act. The allegations claimed that Preferred Care and its various related entities submitted claims to Medicare after providing worthless services to patients and also participated in upcoding other services. USAO EDKY

June 5, 2018

Louisiana-based post-acute healthcare management company Allegiance Health Management will pay over $1.7 million to resolve False Claims Act allegations it billed Medicare for intensive outpatient psychotherapy services to hospitalized patients who did not need the services, received inappropriate levels of treatment, or were provided nontherapeutic treatment. The settlement also resolves claims Allegiance Health Management failed to provide treatment pursuant to an individualized treatment plan and neither tracked nor document patient progress adequately. The suit was brought by whistleblower and former Allegiance employee Ryan Ladner, who will receive a $300,000 share of the settlement. DOJ

May 18, 2018

New York podiatrist Perrin Edwards pled guilty to billing Medicare and private insurance companies for medical services he had not performed and for upcoding normal nail trimming, which is not reimbursable, to nail debridement, a covered service. Edwards will pay a $5,000 fine, serve one year of probation, and perform 50 hours of community service. USAO NDNY

May 14, 2018

Missouri-based podiatry provider Foot Healers agreed to pay the United States $125,000 to settle allegations the company violated the False Claims Act by using improper billing modifiers to inflate Medicare claims and falsely upcoding routine toenail trimmings performed on Medicare patients by claiming the service provided was medically necessary toenail debridement. USAO EDMO

May 14, 2018

Houston-based healthcare provider Memorial Hermann Health System agreed to pay nearly $2 million to resolve allegations it admitted Medicare patients for surgical procedures to three company-owned hospitals, then fraudulently billed for the services provided to these patients at inpatient rates when it should have billed at lower outpatient rates. USAO SDTX

May 4, 2018

New York City-based urgent care company CityMD agreed to pay roughly $6.6 million to settle claims it violated the False Claims Act by billing Medicare for services rendered by physicians who did not actually perform those services and for more expensive and complex services than were actually provided to patients. The allegations originated in a whistleblower lawsuit filed under the qui tam provisions of the False Claims Act. DOJ
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