Articles Tagged with Medicare Fraud

Medicare-fraud-300x200Fake Treatments and Paperwork Lead to Arrest in Medicare Fraud Case

A physician has been indicted for stealing nearly $1 million in Medicare fraud scheme that also included private insurance. Dr. Pranav Patel, of the Chicago area, allegedly submitted fake insurance claims for medical tests and exams that were never conducted.

The Scam

pharmacy-fraud-300x200Massive Pharmacy Fraud Scheme Involved Bribes for Patient Information

A Florida man was sentenced to 15 years in prison for pharmacy fraud that involved $100 million in scams. The wide-reaching scheme impacted private insurance companies, and Medicare and TRICARE.

The Pharmacy Fraud

Ambulance company employeeAharon Aron Krkasharyan, 54, of Los Angeles, California, was sentenced by U.S. District Judge George H. Wu of the Central District of California, who also ordered Krkasharyan to pay $484,556 in restitution to Medicare, jointly and severally with his co-conspirators, who await sentencing.  On Nov. 27, 2017, Krkasharyan pleaded guilty to one count of conspiracy to commit health care fraud. According to court documents, during the course of the conspiracy, Mauran submitted over $28 million in claims to Medicare.  Krkasharyan’s co-defendants admitted that at least $6.6 million of those claims were false and fraudulent claims for medically unnecessary transportation services.  Medicare paid at least $3.1 million on those false and fraudulent claims.

Krkasharyan was employed as the Quality Improvement Coordinator for Mauran Ambulance Inc. (Mauran) of San Fernando, California, an ambulance transportation company operating in the greater Los Angeles area that provided non-emergency services to Medicare beneficiaries, many of whom were dialysis patients.  As part of his plea, Krkasharyan admitted that between June 2011 and April 2012, he conspired with other Mauran employees to submit claims to Medicare for ambulance transportation services for individuals who did not need such services.  Krkasharyan also admitted that he and his co-conspirators instructed Mauran emergency medical technicians to conceal the patients’ true medical conditions by altering paperwork and creating fraudulent reasons to justify the ambulance services.

Krkasharyan was charged along with Toros Onik Yeranosian, 55, the former owner of Mauran; Oxana Loutseiko, 57, the former general manager of Mauran; and Maria Espinoza, 47, a former employee of a Los Angeles dialysis treatment center.  Yeranosian, Loutseiko and Espinoza each pleaded guilty and are pending sentencing.  The former dispatch supervisor at Mauran, Christian Hernandez, 37, who was previously charged in the case, has also pleaded guilty and awaits sentencing.

New Oaklawn Investments, LLC, d/b/a Oaklawn Health and Rehabilitation Center and Elmcroft Senior Living, Inc., a Louisville based skilled nursing facility, agreed to pay $5,191,470 to resolve allegations that it violated the False Claims Act by submitting false claims for payment to the Medicare Program, announced United States Attorney Russell M. Coleman.

“Today’s settlement is the result of this office working in a coordinated effort with Medicare’s Unified Program Integrity Contractor, AdvanceMed, to ensure that taxpayer dollars are not misspent – especially when providing vital services to our senior community,” stated United States Attorney Russell Coleman. “The more than 5 million dollar settlement underscores our continued commitment to uncovering health care fraud.” Oaklawn is a for-profit skilled nursing facility with 128 beds located in eastern Jefferson County, Kentucky, that was managed by Elmcroft.

The government contends that during the period from February 26, 2007 through February 26, 2010, Oaklawn improperly billed Medicare for patient rehabilitation services at the resource utilization (“RUG”) Code Series Rehabilitation Ultra High and Rehabilitation Very High, for certain services that were not reasonably or medically necessary.

SightLine Health LLC (SightLine), which operates radiation therapy centers throughout the United States, will pay $11.5 million to settle a False Claims Act lawsuit alleging that it knowingly submitted claims to the Medicare program that violated the Anti‑Kickback Statute.  Together with Integrated Oncology Network Holdings LLC (ION), which acquired SightLine in 2011, SightLine has agreed to pay the government up to $11.5 million. The Anti-Kickback Statute is intended to ensure that a physician’s medical judgment is not compromised by improper financial incentives and instead is based on the best interests of the patient.  It prohibits anyone from offering, paying, soliciting, or receiving remuneration to induce referrals of items or services covered by Medicare, Medicaid, and other federally funded programs.  Claims submitted in violation of the Anti-Kickback Statute may subject the claimant to liability under the False Claims Act.

The settlement  resolves allegations that SightLine violated the Anti-Kickback Statute and the False Claims Act by targeting physicians that were able to refer patients to its cancer treatment centers, and paid those physicians a share of its profits pursuant to investment arrangements that were set up to allow physicians to profit from their referrals.  Specifically, the United States alleged that SightLine formed a series of leasing companies in which referring physicians were permitted to invest, and through which SightLine allegedly distributed the profits that its physician-investors generated by referring cancer patients for radiation therapy.The allegations resolved by the settlement were brought in a lawsuit filed under the qui tam, or whistleblower, provisions of the False Claims Act. The whistleblower was represented by the firm Morgan Verkamp. The act permits private parties to sue on behalf of the government when they believe that defendants submitted false claims for government funds and to share in any recovery.  The act also allows the Government to take over the case, as it did here in part.  The whistleblower will receive up to $1.725 million.   “Investment arrangements that are structured to improperly compensate physicians for referrals can encourage physicians to make decisions based on financial gain rather than the best interest of their patients,” said Acting Assistant Attorney General Chad A. Readler of the Justice Department’s Civil Division.  “The Department of Justice is committed to preventing illegal inducements, in whatever form, that undermine the integrity of our public health programs.”

“As the professionals charged with recommending and referring medical procedures for our community, physicians’ primary motivation must remain the well-being of their patients,” said U.S. Attorney Erin Nealy Cox.  “Today’s settlement demonstrates our determination to eliminate complex business ventures that improperly interpose financial considerations into our physicians’ medical judgment.” In addition to resolving their alleged False Claims Act liability, ION, SightLine, and their related entities have entered into a five-year Corporate Integrity Agreement with the HHS-OIG.  This agreement is intended to increase accountability and transparency and to deter future misconduct.  The Corporate Integrity Agreement includes internal and external monitoring of the relationships between the ION and SightLine entities and referring physician investors.

 
A New Jersey man is facing fraud charges after a federal grand jury agreed he took advantage of senior citizens. The man is accused of operating a nonprofit with the intention of defrauding people with unnecessary tests. According to Tapinto.net, Seth Rehfuss, 43, of Somerset NJ, used a nonprofit agency called Good Samaritans of America to commit “health care fraud and conspiracy to wrongfully access individually identifiable health information and to pay illegal remunerations to health care professionals.” The fraud lasted from July 2014 through December 2015, while he managed to deceive low-income seniors. The victims were told Good Samaritans of America was a nonprofit that helps seniors understand the federal benefit programs. But, the article says, the organization was a fraud. He actually used the nonprofit to scare victims into genetic testing. The indictment says Rehfuss used fear-based tactics by suggesting the seniors could be at risk for heart attacks, strokes, or cancer and even suicide if they did not have the genetic testing. He told them he was offering “personalized medicine.”

The article says that Rehfuss took DNA swabs from senior citizens in their homes and community rooms during fear-based presentations designed to get their personal information. He apparently tried to recruit healthcare providers on Craigslist. Once they signed a contract the healthcare providers received requisition forms that often included a patient’s personal information, Medicare information, medication lists, and diagnosis codes. The healthcare providers that choose to cooperate were paid to sign-off on requisition forms authorizing testing for patients “they never examined”.

The fraudulent scheme racked up over $1 million in Medicare costs at two laboratories. He also shared his commissions with a co-conspirator, Sheila Kahl. Together authorities say they were planning to expand to Georgia, Delaware, Virginia, Maryland, Pennsylvania, South Carolina, Michigan, Mississippi, Florida, Tennessee, and Arizona. The healthcare fraud conspiracy means he could be put away for a decade and pay a $250,000 fine, or twice the gross gain or loss from the offense. The conspiracy charge carries a possible 5-year sentence and a $250,000 fine, or twice the gross gain or loss from the offense. His co-conspirator, Sheila Kahl pleaded guilty and is awaiting sentencing.

The Brattleboro Memorial Hospital will $1,655,000 to the United States and the state of Vermont  to settle claims that it “knowingly”  presented “false claims for payment to Medicare and Medicaid.” The U.S. Attorney’s Office alleged that between January 2012 through September 2014, “BMH knowingly submitted or caused to be submitted a number of outpatient laboratory claims lacking documentation necessary to support reimbursement by Medicare and Medicaid.” According to a press release, a whistleblower Amy Beth Main filed a complaint against the hospital under the federal False Claims Act. Qui tam lawsuits are a type of whistleblower lawsuit that rewards whistleblowers in successful cases where the government recovers funds lost to fraud. According to Norman Watts, of Watts Law Firm, in Woodstock, Main will receive between 15 and 20 percent of the settlement, from which he will recover his attorney fees. Ms. Main worked for the hospital in an administrative role in the financial services department.

The case was investigated by the United States Attorney’s Office for the District of Vermont, with assistance from the Office of the Inspector General of the Department of Health and Human Services, and by the Medicaid Fraud and Residential Abuse Unit of the Vermont Attorney General’s Office.

chiro-300x200
A report just issued by the U.S. Department of Health and Human Services Office of Inspector General reveals that the Government overpaid chiropractors for their services an average of $257 million to $304 million per year over a 6 year period.  During this period Medicare paid a total of $2.9 BILLION for chiropractic services.  The improper payments were made for services that were medically unnecessary or not sufficiently documented.   Hundreds of millions of dollars in taxpayer moneys were paid to chiropractors for services that did not meet Medicare requirements.

The OIG concluded that chiropractic fraud is a major concern. One of the problems is the way payments are made, according to the report. Most Medicare claims are processed and paid without a review of the underlying medical records to support the claim.

Scrutiny of chiropractors invoicing of Medicare will increase now. In addition, fraud investigations have resulted in criminal cases where the chiropractic claims were submitted where services that were never performed and where the services were performed without a valid chiropractic license. In addition, criminal cases were brought where patient records were falsified or where chiropractic services were billed where they are not covered by Medicare, as with massage or acupuncture. These investigations resulted in 11 chiropractors being incarcerated and $7.6 million in restitution.

 

pharmacist-300x200A sharp eyed pharmacist James Garbe has been awarded $9.3 million as his reward for revealing Medicare D and Tricare  overbilling by Kmart. Mr. Garbe noticed that his own prescription was filled a a non-Kmart competitor pharmacy which charged Medicare less than Kmart did. His subsequent review of Kmart’s reimbursement claims unveiled a two-tiered pricing system, one for customers who paid cash and higher amounts for those with insurance including Medicare. The effect was that Medicare was routinely overbilled. For example, in one case, Kmart reportedly sold a 30-day supply of a generic version of a prescription drug for $5 to cash customers. Then it filed for reimbursement from the government for $152 for that same drug for its Medicare customers. Garbe filed his whistleblower suit in 2012.

The False Claims Act (FCA) makes it illegal for a person or company to make a false filing in any federal health care program. The law allows individuals who reveal fraud to collect a percentage of what the government recovers. Garbe retained a pharmaceutical economist, Dr. Joel Hay, to analyze mountains of reimbursement data. Dr. Hay’s work revealed that Kmart charged nearly all its cash customers “discount program” prices. Garbe also hired an auditor, who testified that, under industry practice and the terms of over 1,000 contracts between Kmart and Medicare Part D Benefit Managers and Plan Sponsors, Kmart should have based its reimbursement requests to the insurance companies handling Medicare Part D on its “discount program” prices. Dr. Hay’s examination revealed that Kmart instead used significantly higher prices when submitting those requests, and was thus reimbursed at a much higher level.

Jeffrey Newman represents whistleblowers but not in this case.

CHS-300x200A Revived Lawsuit Against Community Health Systems Is Moving Forward

The court system is reviving an $891 million securities fraud lawsuit against Community Health Systems. According to Modern Healthcare, the shareholder’s allegations of securities fraud deserve another look. A federal appeals court agrees the company may have intentionally inflated its financial outlook.

The Lawsuit