Articles Posted in Healthcare Fraud

IMG_0004-300x200Nabil Fakih, a licensed pharmacist, Michigan Board of Pharmacy member, and owner of a Dearborn Heights drug store, was charged with healthcare and wire fraud and indicted by a grand jury. The Indictment accused Fakih of wrongfully taking millions of United States dollars from Medicare, Medicaid and Blue Cross Blue Shield (BCBS), dating back to 2011.

According to the indictment, Fakih is accused of falsely submitting claims on behalf of Dial Drugs. He was reported to be overbilling Medicaid and Medicare by $569,670 while overcharging BCBS by $558,079.

Fakih and others billed insurance companies for prescription drugs such as the antipsychotic medication, clozapine, and the sedative alprazolam. Claims for these drugs were on behalf of people who had died prior to the claimed date of delivery. This is according to government allegations.

big-pharma-300x196Jazz Pharma, Alexion, and Lundbeck were the subject of SOJ lawsuits asserting kickbacks and committing general violations of Medicare laws. The United States Department of Justice has decided to agree to a settlement of $122.6 million in total from these three alleged Medicare violators.

The drug companies were accused of offering remuneration in hopes of encouraging patients to purchase their medications. They would pay kickbacks, a form of negotiated bribery, to patients of Medicare and Civilian Health and Medical Program (ChampVA) under the guise of charitable organizations that subsidized the co-pays. This is not an uncommon practice, but it is one many law enforcement programs are attempting to discontinue.

The DOJ states that in this case, the companies violated the Federal False Claims Act. This act is a way of imposing liability onto anyone, be it a group or individual, that has been discovered interfering with government-funded programs such as in this case with Medicare. This is one of the government’s main tools in defending against fraudulent acts.

MedicareFull coverage of Medicare Part A benefits is said to be at risk within seven years as funding begins to run out. This could potentially lead to long-term effects that will be devastating to a large number of nursing homes and those who operate them, as well as the healthcare system as a whole.

Generally, Medicare Part A is responsible for covering inpatient care in a hospital, skilled nursing facility care, hospice care, and through home health care programs. Medicare is based on the laws set by the state and federal government, and it is up to national and local decision-makers to set the coverage standards.

The Hospital Insurance (HI) Trust Fund directly supports Medicare Part A benefits, which include skilled nursing services and facilities. This fund will only have the means to help provide these benefits up until 2026, according to the findings of the Medicare Board of Trustees. These are the same findings recorded last year and display a serious potential for a decline in spending on skilled nurses.

Newmanheadphoto-240x300False Claims Act lawsuit reveals upcoding of urgent care visits by CareWell in Massachusetts and Rhode Island at the expense of Medicare and Medicaid

BOSTON, MA. ***FOR IMMEDIATE RELEASE*** CareWell Urgent Care Centers, an urgent care company which operates seventeen (17) urgent care centers in Massachusetts and one (1) in Rhode Island, will pay over $2.1 million dollars with interest to settle False Claims Act whistleblower claims against it, for its fraudulent billing of Medicare and Medicaid for services it provided which were unrelated to patients’ individual medical needs.  The original whistleblower case was filed on behalf of the federal and state Governments by Registered Nurse Practitioner Aileen Cartier of Massachusetts, who worked in some of CareWell’s clinics from 2016 to early 2018. Ms. Cartier is represented by Attorney Jeffrey A. Newman of Massachusetts.

The fraudulent billing by CareWell included requirements that all of its providers give the patients histories and physical examinations which far exceeded the purposes for which they went to the clinics. According to the Complaint, CareWell’s physicians, nurse practitioners and other medical personnel were directed by management to examine and document at least 13 body systems during the medical history inquiries and at least 9 body systems during physical examinations, even if, for example, the patient’s original complaint was as simple as a splinter in the finger. This was done so that CareWell could upcode claims to a Level 4 code in order to receive more reimbursement funds. In addition, the evidence revealed that CareWell’s management informed medical personnel that the mandate of inquiring into body symptoms unrelated to a patient’s specific medical complaints or symptoms was a requirement imposed by CareWell’s malpractice insurance carrier. According to the Settlement Agreement: “…no malpractice insurance carrier imposed this requirement on CareWell.”

Medicaid fraudWaveney Blackman, the owner of durable medical equipment company WaveCare Health services, has been charged with one act of healthcare fraud for filing claims to Medicaid for products that were never purchased through her business. Blackman pleaded guilty to these charges after one month and has been sentenced to 42 months in prison and ordered to forfeit $9.4 million, the sum of WaveCare’s proceeds from fraudulent claims.

During the years of 2010 to 2016, Blackman filed multiple claims to Medicaid for incontinence products, wound care supplies, and other pieces of durable medical equipment that resulted in revenue of $9.4 million. None of these products were ever given to Medicaid clients or even requested by one. These fraudulent claims were filed by Blackman herself, along with the assistance of her employees through a WaveCare biller.

Within one month of being charged, Blackman signed a plea agreement that detailed the illegal actions taken, as well as the proceeds she received from them. The government has seized a Mercedes, seven properties, and money traced to two separate bank accounts, and the judge ordered Blackman to pay the total of $9.4 million WaveCare reportedly received in fraudulent claims. She will also be sentenced to 42 months in prison.

NC-health-care-fraud-300x199Mental health company owner, Catinia Denise Farrington of Cyprus, Texas, pleaded guilty to health care fraud and tax evasion in September of 2018. As of March 1st, 2019, she has been sentenced to 60 months in prison after profiting $4 million from Medicaid and just under $400,000 from her tax evasion scheme.

Health Care Fraud Conspiracy

According to prosecutors, Farrington owned a mental health care company out of North Carolina, Durham County Mental Health and Behavioral Health Services, LLC. Through this company, she submitted thousands of fraudulent claims to Medicaid for services that were never performed. These incidents occurred between 2011 and 2015, but this is not the only fraudulent activity that Farrington participated in during this time.

Australia whistleblower lawsThose looking to report corruption, fraud, tax evasion, and other forms of misconduct in the corporate world can finally get the protection they deserve as new whistleblower laws in Australia clear federal parliament.

Corporate whistleblower laws introduced in late 2017 have managed to pass the lower house in early 2019. These laws put into place offer greater protection for anyone wishing to voice concerns about fraudulent activities within a division of the corporate world.

Corporate crime is an illegal act that is committed by a company or business with the goal of giving the company a boost or advantage they normally would be unable to receive. Examples of this are all over the world and are committed by even some of the best-known brands. Many in the U.S. may even recall back in 2014 when Rite Aid, one of the largest drug stores, was required to pay almost 3 billion for violating the False Claims Act by allegedly using gift cards to sway those on Medicare and Medicaid to switch their prescriptions to their pharmacies. This would be considered an act of bribery, and one of the many types of corporate crime. Corporate crime has cost many countries a considerable amount, and so whistleblowers, those who have set out to inform others about illicit activity, are one of the best defenses we have to fight against this type of crime.

Medicare-fraud-300x200Rossana Ramirez, a once certified nursing assistant, was discovered to be helping run a business in West Miami-Dade that is responsible for $7 million in health care fraud. After pleading guilty Ramirez was stripped of her license permanently through an Emergency Suspension Order and is now serving time at a federal detention center with a release date of June 2022.

Rossana Ramirez was registered in the state corporation registration as the vice president of a company titled F&E Home Health Care. While Rossana Ramirez is currently taking the heat from the Florida Department of Health, her husband Evelio Ramirez Jr. is also involved as the president of F&E. He will soon be starting his sentence of three years and ten months in federal prison himself. Both husband and wife are 59 and will both serve their time. Their pleas of guiltily were fairly straightforward and show that this act of fraud is not very uncommon from what has already been seen from healthcare fraud schemes in South Florida.

F&E is accused of paying kickbacks, a form of negotiated bribery in which a commission of sorts is given in return for services rendered, to those who receive Medicare and Medicaid to become F&E patients. Additionally, some of these patients did not even require home healthcare and the services promised were not often necessary or even provided at times. F&E is also accused of paying recruiters of Medicare and Medicaid recipients to promote their health services for them.

pharmacy-fraud-300x199The pharmaceutical industry in Pasadena is much like the rest of the United States. There are certainly an influx of individuals who receive Medicare using these services for particular ailments and diseases that accompany being older than 65 years old. However, a local Pasadena pharmacy, Akhtamar Pharmacy, was abusing the Medicare funds provided for those particular individuals. Although the pharmacy owner did not act alone, she was able to steal $1.3 million dollars from the Medicare system.

Pasadena Pharmacy Owner Convicted for Medicare Fraud

Although the pharmaceutical industry is driven by a purpose to help those who need medication, it can also be a place for fraudulent acts to occur. With so much paperwork to be completed, many individuals find themselves taking advantage of the system by falsifying numbers or providing inaccurate invoices. Unfortunately, this was the case in a Pasadena pharmacy. A 39-year-old pharmacy owner, Tamar Tatarian, was convicted on one count of healthcare fraud and two counts of wire fraud at Akhtamar Pharmacy in Pasadena. It is believed that she committed the fraudulent acts which amounted to $1.3 million dollars in total.

new-brestmilk-device-300x200As matured human beings, we generally have a plethora of options when it comes to where we receive our nutrients, but for those in the fragile first 12 months of life, the choices are severely limited. Basically, the choices come down to either the less nutrient sufficient formula, or the more nutrient complex breast milk. So those who desire a more nutrient-rich diet for their infant will generally have to choose breast milk.

Recently the U.S. Food and Drug Administration permitted marketing of the Miris Human Milk Analyzer after reviewing it through the De Novo premarket review pathway, a regulatory pathway for new low-to-moderate-risk devices. This device and diagnostic test is designed to examine breast milk in order to accurately measure its nutrient composition. Breast milk composition will often vary depending on the individual, and so a test which can examine their nutritional value can be a valuable guide. The findings from this test can include concentrations of fat, carbohydrate, protein, total solids, and energy; providing healthcare professionals and parents of newborns with vital information.

The Miris Human Milk Analyzer is a prescription device used by professionals that operates by analyzing samples of human milk through an infrared spectroscopy system. This system will produce quantitative measurements of the contents contained in the milk. There are conditions that limit the information taken by the machine though, such as an interference from medication that is generally used by nursing mothers.