Articles Posted in Medicare Fraud

The Department of Justice is investigating 21st Century Oncology Holdings Inc. on allegations that it knowing billed for services that were not medically necessary and for services not rendered, according to the Wall Street Journal. Subpoenas issued to the company relate to a radiation therapy which the company asserts is used only for medical reasons and not profits. Continue reading

Bostwick Laboratories, Inc., an anatomic and pathology lab based in Uniondale, New York, has agreed to pay the United States$6,048,000 to resolve allegations regarding violations of the False Claims Act.

The qui tam complaint was filed in May 2008. It alleges that Bostwick Laboratories improperly billed Medicare and Medicaid for tests and services referred in violation of the Anti-Kickback Statute and for tests performed without a doctor’s order or consent. The Justice Department decided in June 2011 not to intervene in the case. In 2012, Senior District Judge S. Arthur Spiegel issued a well- reasoned order denying the defendants’ motions to dismiss. U.S. ex rel. Daugherty v. Bostwick Laboratories, et al., 2012 U.S. Dist. LEXIS 178641 (S.D. Ohio Dec. 18, 2012).

The case against Bostwick Laboratories settled after the company entered into settlement discussions with Mr. Daugherty and the United States based on its inability to pay the full value of the damages sought in the qui tam action.

Two managers and operators of three medical clinics with Medicare fraud and conspiracy to pay illegal kickbacks for medical procedures that were never actually provided.

Hovik Simitian, 47 and Anahit Shatvoryan, 49,  were each charged in with one count of conspiracy to commit health care fraud, six counts of health care fraud and one count of conspiracy to pay health care kickbacks.

According to allegations in the indictment, Simitian and and Shatvoryan managed and operated three medical clinics-Columbia Medical Group Inc., Life Care Medical Clinic and Safe Health Medical Clinic-out of two suites in the same Los Angeles office building. From February 2010 through June 2014, Simitian and Shatvoryan paid marketers illegal kickbacks to recruit Medicare beneficiaries to the clinics. They then submitted false claims to Medicare for services-including procedures such as anorectal manometry and nerve conduction tests-that were not medically necessary and never actually provided.

Atlantic Health System health system has been charged by a whistleblower that it designated Medicare beneficiaries as inpatients and prolonged their hospital stay to qualify them for skilled nursing care. In the case, filed in federal court, a Judge has ruled that this case may proceed and denied a Motion To Dismiss by the Atlantic Healthcare System. The whistleblower contends that the defendants improperly billed for inpatient rather than observation care to inflate their reimbursements, and that they “essentially stated” that they had full discretion to classify patients “as they pleased,” according to court documents

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 CHS agreed to pay $98.15 million to settle false claims allegations over its billing for inpatient admissions that should have been outpatient or observation services from 2005 through 2010, said DOJ, which intervened in the complaints.

The Inspector General of the Department of Health and Human Services says that $30 million paid by Medicare for HIV drugs in 2012 may be questionable and fraudulent.  The payments were made under the Medicare Part D programAccording to the Washington Post, reporting on the IG report, in Detroit, a 77-year-old woman purportedly filled $33,500 worth of prescriptions for 10 different HIV medications. But there’s no record that she had HIV or that she had visited the doctors who wrote the scripts.

A 48-year-old in Miami went to 28 pharmacies to pick up HIV drugs worth nearly $200,000, almost 10 times what average patients get in a year. The prescriptions were supposedly written by 16 health providers.

 Another  patient received $17,500 worth of HIV drugs — and none the rest of the year. She acquired more than twice the recommended dose of five HIV drug ingredients.

The United States Department of Justice (“DOJ”) has settled seven whistleblower lawsuits  against Community Health Systems, Inc. (“CHS”) for a total of over $98 million.  One  was brought by Dr. Thomas L. Mason, M.D., a board-certified emergency physician, who had filed a whistleblower case against CHS in the United States District Court for the Western District of North Carolina.

The alleged improper conduct by CHS relates to the inpatient admission and treatment of government healthcare program beneficiaries 65 and older who originally presented to the Emergency Department(s) (“ED”) of 119 CHS hospitals located throughout the United States. The settlement covered claims paid by Medicare Part A for those patients whose hospital stay was two (2) days or less and who were treated for the following conditions: chronic obstructive pulmonary disease; heart failure & shock; cardiac 4 arrhythmia & conduction disorder; syncope & collapse; chest pain; esophagitis, gastroenterology & misc. digestive disorders; nutritional and miscellaneous metabolic disorders; kidney and urinary tract infections.

CHS is publicly traded on the NYSE as “CYH.” In early 2014, CHS acquired Florida-based Health Management Associates, creating one of the largest for-profit hospital companies in the country. According to SEC filings, CHS directly or indirectly owns and operates 206 hospitals in twenty-nine states, and has nearly $27 billion in assets.  The settlement does not include hospitals that CHS acquired from Health Management Associates (HMA) in January 2014.

The Government Accounting Office says that Medicaid wrongfully paid out more than $14 Billion to managed care organizations (MCO’s) which partner with states in providing health care services to patients. The improper payments included services that were not necessary, never performed or weren’t eligible for coverage.

MCO’s allow Medicaid beneficiaries to get their care through state run programs and are rapidly increasing. States that expand Medicaid programs through the Affordable Care Act will receive 100 percent reimbursement from the federal government for MCO’s in the next two years.

In 2013, Medicaid covered almost 72 million Americans and the program cost the taxpayers $430 billion annually. There are 7 million new Medicaid clients resulting from the new healthcare law.

Medicare Insurance plans are fraudulently over-billing Medicare, costing the US taxpayers hundreds of millions of dollars, according to Medicare auditors. Nearly 16 million elderly Americans have Medicare Advantage Plus, one of the Medicare insurance plans involved in the over-payments.

Five other plans and Medicare Advantage Plus were found to have been overpayed from approximately $650 million.

Medicare pays higher rates for people who are sicker as their care is more expensive. However, the audit showed that these insurers targeted the patients because they were more ill and over billed for services.

 The federal government  now targeting physicians who buy prescription drugs from companies outside of the United States and then offer them to their patients, even though the medicines were not manufactured in facilities inspected or approved by the U.S. Food and Drug Administration, as required by law. The federal cases involve brand-name drugs, such as the cancer treatments Avastin and Rituxan, which were imported from Turkey, India, the European Union or other countries, but were not approved for import or sale in the United States.

Recent cases against two East Tennessee cancer doctors, for instance, have brought convictions, with one defendant serving a two-year federal prison term and the other still awaiting sentencing.

In the East Tennessee cases, the imported drugs were administered intravenously to cancer patients in clinics in Greeneville and Johnson City.