Articles Posted in Healthcare Fraud

Medicare fraudFighting Medicaid Fraud

Hearing the term Medicaid fraud may conjure up images of lawyers and government officials, but the true cost is actually much closer to home for many people. Fraud and abuse in Medicaid cost taxpayers billions of dollars every year. Funds intended to help the sick end up being wasted.

But worse than the wasted time is the risk to patients caught up in unnecessary procedures that just line the pockets of unscrupulous health care companies. Imagine if you found out that your child had an unnecessary surgery just so that agency could make a few hundred dollars.

1-1-300x198Upcoding In The ER Could Be Stealing U.S. Tax Dollars

It’s an old and shady practice that has been in the forefront of Medicare and Medicaid fraud for years. Upcoding can hit taxpayers hard and drive emergency room bills to the thousands.

What is Upcoding?

Ri Bravo Texas Mayor Francisco Pena, a licensed physicians has been indicted with federal charges of money laundering and conspiring with three others to defraud Medicare of $150 million in allegedly phony hospice and home health care services. The 11-count indictment unsealed Wednesday charges Dr. Pena with taking kickbacks to refer patients for services for which they did not qualify.

Charged with bribing Pena and other medical directors in the conspiracy are Merida Health Care Group owners Rodney Mesquias, 47, of San Antonio; Henry McInnis, 47; and Jose Garza, 40, both of Harlingen.  All four men are charged with conspiracy to commit health care fraud and conspiracy to commit money laundering. Mesquias and McInnis also are charged with obstructing justice by producing false and fictitious records to a federal grand jury, and instructing the others to do so.

Prosecutors say the men fraudulently kept patients on hospice services for years in order to allow them to continue to bill Medicare. Pena was elected to a four-year term as mayor of Rio Bravo, pop. 4,794, in November 2014. Rio Bravo is on the Rio Grande, 14 miles south of Laredo.

healthcare-fraud-300x180Wyoming Psychologist Will Serve Prison Time for Health Care Fraud

A Wyoming Psychologist has admitted he committed health care fraud by falsely filing Medicaid claims. Gibson Buckley Condie, 57, of Powell, Wyoming has been sentenced to three years in prison and ordered to approximately $2.28 million in restitution, according to Justice.gov.

The Scheme

The Justice Department Nets Billions in 2017 Through Healthcare Fraud Caseshealthcare fraud

The Department of Justice announced that in 2017 it recovered $2.4 billion from federal healthcare fraud cases. According to Health Payer Intelligence, this total added up to well over half of all the money recovered by the DOJ fraud investigations.

Healthcare fraud investigations account for 64% of the $3.7 billion recovered by DOJ across all industries, including housing and mortgage sectors, small business contracts, military contracts, and additional areas of oversight that fall under the False Claims Act.

hep-300x200It Will Now be Easier for Medicaid Patients to Get Treatment for Hepatitis C in Colorado

Controversial Medicaid restrictions are being pulled back in Colorado. Now, patients seeking treatment for Hepatitis C will no longer have to be in an advanced state of liver failure to have access to certain drugs and procedures. The move comes after a lawsuit called into question the state’s practice of only providing meds to the sickest of patients.

Lawsuits Filed

opioid fraudOn November 29, 2017 Charles J. Gartland, D.O., age 59 of Cochranville, PA was indicted by a federal grand jury on charges of opioid diversion and health care fraud.

United States Attorney David J. Freed said the charges of the indictment were handed down based on the belief that Gartland headed up a plan to defraud two health care benefit programs, Wellspan Health of York, PA and Medicare, by writing 221 prescriptions written in the names of three of his family members between the dates of September 2014 and August 2017.  The prescriptions were for the opiates Hydrocodone, Oxycodone, Fentanyl, Morphine and other controlled substances. The majority of the prescriptions were written for Hydrocodone-Ibuprofen.

The indictment notes that the prescriptions were not written for treatment of the family members but rather for the personal use of Dr. Gartland. Because of this, the prescriptions were not written in the realm of professional medical practice and were not used for a medical reason.

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AmerisourceBergen Specialty Group,  a  drug wholesale company  providing pharmaceuticals a, pled guilty to illegally distributing misbranded drugs and agreed to pay $260 million to resolve criminal liability for skirting regulatory oversight. The Government says that Between 2001 and 2014, the group’s now-defunct subsidiary Medical Initiatives prepared millions of syringes that had been filled with cancer drugs and shipped them to providers in all 50 states.  Medical Initiatives removed the drugs from their original glass vials and repackaged them into plastic syringes in an unclean and unsterile environment, allowing the company to sell excess drug product in the vials known as “overfill,” according to court records. It combined the contents of multiple vials in a process known as “pooling,” despite many of the vials carrying a “single-use” designation.

In order to avoid the Food and Drug Administration’s regulatory oversight, AmerisourceBergen Specialty Group did not register Medical Initiatives as a repackager or manufacturer with the agency, records show. Instead, the group portrayed Medical Initiatives as a state-regulated pharmacy, exploiting an exemption to the FDA registration requirement that is reserved for legitimate pharmacies, not for manufacturers or repackagers, authorities said.

“Injectable drugs prescribed for patients—especially vulnerable cancer patients—must be pure, sterile and produced in an FDA-compliant facility that is within the supply chain that FDA oversees,” special agent in charge Mark McCormack of the FDA Office of Criminal Investigations Metro Washington Field Office said in a statement. “We will continue to pursue and bring to justice those manufacturers who would violate the public’s trust and endanger their health by attempting to avoid FDA’s oversight authority.”

Pharmaceutical companies Mylan Inc. and Mylan Specialty L.P. have agreed to pay $465 million to resolve claims that they violated the False Claims Act by knowingly misclassifying EpiPen as a generic drug to avoid paying rebates owed primarily to Medicaid. Congress enacted the Medicaid Drug Rebate Program to ensure that state Medicaid programs were not susceptible to price gouging by manufacturers of drugs that were available from only a single source. It therefore subjected such single-source, or brand name drugs, to a higher rebate that is payable to Medicaid and that increases to the extent the price of the drug outpaces the rate of inflation. In contrast, generic drugs originating from multiple manufacturers are subject to lower rebates that, at least until recently, were not subject to inflationary adjustments.

The settlement resolves the government’s allegations that Mylan, by erroneously reporting EpiPen as a generic drug to Medicaid despite the absence of any therapeutically equivalent drugs, was able to demand massive price increases in the private market while avoiding its corresponding rebate obligations to Medicaid. Between 2010 and 2016, Mylan increased the price of EpiPen by approximately 400 percent yet paid only a fixed 13 percent rebate to Medicaid during the same period. The government further alleged that although Mylan was well-aware that its drug was not a generic, it nevertheless claimed generic status for EpiPen in the Medicaid program to avoid paying a higher rebate.

The settlement resolves allegations brought in a lawsuit filed under the whistleblower provisions of the False Claims Act, which permits private parties to sue on behalf of the government for false claims for government funds and to receive a share of any recovery. The whistleblower in this case was the pharmaceutical manufacturer, Sanofi-Aventis US LLC. It will receive approximately $38.7 million as its share of the federal recovery.

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The owner and director of nursing of a Houston home health agency was sentenced today to 75 years in prison for her role in a $13 million Medicare fraud scheme.

Marie Neba, 53, of Sugarland, Texas, was sentenced by U.S. District Judge Melinda Harmon of the Southern District of Texas.  In November 2016, Neba was convicted after a two-week jury trial of one count of conspiracy to commit health care fraud, three counts of health care fraud, one count of conspiracy to pay and receive health care kickbacks, one count of payment and receipt of health care kickbacks, one count of conspiracy to launder monetary instruments and one count of making health care false statements.

According to the evidence presented at trial, from February 2006 through June 2015, Neba and others conspired to defraud Medicare by submitting over $10 million in false and fraudulent claims for home health services to Medicare through Fiango Home Healthcare Inc., owned by Neba and her husband, Ebong Tilong, 53, also of Sugarland, Texas.  The trial evidence showed that using the money that Medicare paid for such fraudulent claims, Neba paid illegal kickbacks to patient recruiters for referring Medicare beneficiaries to Fiango for home health services.  Neba also paid illegal kickbacks to Medicare beneficiaries for allowing Fiango to bill Medicare using beneficiaries’ Medicare information for home health services that were not medically necessary or not provided, the evidence showed.  Neba falsified medical records to make it appear as though the Medicare beneficiaries qualified for and received home health services.  Neba also attempted to suborn perjury from a co-defendant in the federal courthouse, the evidence showed.