The case was brought by 7 whistleblowers who brought 6 separate federal lawsuits in the Northern District of California, the District of Nevada, the Northern District of Georgia, and the Western District of Missouri. The whistleblower reward is a combined $9.67 million.

This settlement resolves a slew of allegations including (but not limited to): Billing Medicare for hospice services for patients who were not terminally ill; billing for inappropriately for certain physician-evaluation management services; submitting false claims by providing therapy to certain patients longer than medically necessary; fraudulently assigning patients a higher Resource Utilization Group (RUG) level than necessary; submitting false claims to Medicare Part B by billing for outpatient therapy services provided in the State of Georgia that were not medically necessary or unskilled in nature; submitting false claims to the Medicare and Medi-Cal programs at certain of its nursing homes for services that were grossly substandard and/or worthless and therefore ineligible for payment.

U. S. Attorney John Horn for the Northern District of Georgia said:

Health care providers that falsify claims for unauthorized or unnecessary services steal precious taxpayer dollars, and we will aggressively seek to recover those funds for the program that needs them.

Special Agent in Charge Steven J. Ryan of the Department of Health and Human Services, Office of Inspector General (HHS-OIG) said:

It’s disturbing when health care companies bill Medicare and Medicaid to care for vulnerable patients, but provide grossly substandard care and medically unnecessary services just to boost company profits…We will continue to crack down on medical providers who betray the public’s trust and the needs of vulnerable patients through fraudulent billing and irresponsible practices.

Nolan Auerbach & White is a law firm that prosecutes healthcare fraud cases for courageous whistleblowers under the qui tam provisions of the False Claims Act.  “Doing the right thing matters” is our firm mantra, and making sure that justice prevails is our goal. More information for potential whistleblowers is located on our main website.

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The United States alleged that in 2014, Prestige was approached by Genomix, LLC, which claimed it could perform genetic testing on Prestige’s Medicare residents to determine whether Prestige’s patients were properly metabolizing their medications. According to the allegations, Prestige provided Genomix with insurance, personal medical information and access to patients in nursing homes in Wisconsin and several states for purpose of conducting the testing. Genomix conducted the testing by taking cheek swabs of each Prestige patient and then sending the cheek swab to a laboratory for analysis.

Nursing home operators, like Prestige, place orders with clinical laboratories for medically necessary diagnostic laboratory tests for their residents. In order to be considered medically necessary and thus reimbursable under Medicare, the laboratory test must be ordered by the physician treating the resident.

The United States alleged that Prestige failed to ensure that physician orders were obtained for the genetic testing prior to its being conducted, and that Prestige physicians were not aware of and did not agree with the medical necessity of the testing. The United States also alleged that Prestige failed to ensure that its patients (or, in some cases, their family members responsible for their medical decisions) were appropriately informed of the testing prior to its being conducted and provided with the opportunity to decline the testing.

According to the United States, the lack of physician orders and patient consent in this case was discovered during a survey conducted by state regulators in late 2015.

Lamont Pugh III, Special Agent in Charge for the Office of Inspector General of the U.S. Department of Health and Human Services remarked:

As genetic testing technology is evolving, we see the same types of clinical testing abuses that are evident in more established testing…along with our law enforcement partners, we will investigate and prosecute violations in these newer health care technologies.

More information for potential Medicare fraud whistleblowers is located at the Nolan Auerbach & White main website.

The post Prestige Healthcare Pays Government for its False Billing Role in Genetic Testing Fraud appeared first on Medicare Fraud 101.

“Medical providers who fraudulently seek payments to which they are not entitled will be held accountable,” said U.S. Attorney Zachary T. Fardon for the Northern District of Illinois. “False documentation of treatment is not just flawed patient care; it is illegal.”

“When health care companies boost their profits by misrepresenting the services they bill to taxpayer-funded health care programs, our office will make sure they are held accountable for their deceptive schemes and that they make changes to bill these programs appropriately,” said Special Agent in Charge Lamont Pugh of HHS-OIG.

Dr. Bijan Oughatiyan, a formerly employed by IPC as a hospitalist was the physician whistleblower in this False Claims Act case and will be receiving an approximate $11.4 million whistleblower reward.

More information for potential healthcare whistleblowers is located at Nolan Auerbach & White’s main website.

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Billing Medicare for ambulance rides that were unnecessary or at a higher rate than could be medically justified is unacceptable. Together with our law enforcement partners, we will seek out and stop this fraudulent behavior.

In September 2015, the Department of Health and Human Services, Office of Inspector General released a study entitled, “Inappropriate Payments and Questionable Billing for Medicare Part B Ambulance Transports.” Many tens of millions of dollars billed to Medicare were the result of improper payments and questionable billing by ambulance suppliers.

For example, Medicare paid for ambulance transports that did not meet certain requirements to justify payment such as transports that were to or from non-covered destinations such as physicians’ offices.  In other claims examined, beneficiaries did not receive Medicare services at either pick-up or drop-off locations, or anywhere else!  Questionable billing issues tended to be concentrated in metropolitan areas; which included unusually high average mileage for transports provided to beneficiaries in urban areas.  This study not only concluded that Medicare has been quite vulnerable to ambulance transport fraud but that ambulance transports warrants scrutiny given its vulnerability.

Not all ambulance fraud can be found by the Government on its own. Medicare fraud continues to deprive the public fisc and rewards wrongdoers, unless courageous whistleblowers come forward.  The law firm of Nolan Auerbach and White devotes all of its resources to representing healthcare whistleblowers.

The post Medicare Dollars Are Still Siphoned Through Ambulance Fraud appeared first on Medicare Fraud 101.

This is the third highest annual recovery in False Claims Act history, bringing the fiscal year average to nearly $4 billion since fiscal year 2009, and the total recovery during that period to $31.3 billion.

Of the $4.7 billion recovered, $2.5 billion came from federal losses in the health care industry, including drug companies, medical device companies, hospitals, nursing homes, and laboratories.  The Department of Justice was instrumental in recovering additional millions of dollars for state Medicaid programs.

“Congress amended the False Claims Act 30 years ago to give the government a more effective tool against false and fraudulent claims against federal programs,” said Mizer. He continued:

An astonishing 60 percent of those recoveries were obtained in the last eight years.  The beneficiaries of these efforts include veterans, the elderly, and low-income families who are insured by federal health care programs; families and students who are able to afford homes and go to college thanks to federally insured loans; and all of us who are protected by the government’s investment in national security and defense.  In short, Americans across the country are healthier, enjoy a better quality of life, and are safer because of our continuing success in protecting taxpayer funds from misuse.

Nolan Auerbach & White represents only healthcare fraud whistleblowers. Please visit our main website for more information.

The post Civil Health Care Fraud Recoveries Have Exceeded $2 billion for the Seventh Consecutive Year appeared first on Medicare Fraud 101.

While this is an expansion of Anti-Kickback Statute (AKS) enforcement, it tracks the language of the Statue, which reaches “any person for referring, recommending or arranging for the purchase” of any item for which payment may be made under a federally-funded health care program. Thus, for example, the AKS potentially applies a kickback recipient who recommends a particular manufacturer’s product to a healthcare provider.

Indeed, this very fact scenario was at the heart of a recent $28 million False Claims Act recovery involving Omnicare, the nation’s largest nursing home pharmacy. In that case, it was alleged that Omnicare solicited and received kickbacks from pharmaceutical manufacturer Abbott Laboratories in exchange for its consultant pharmacists to recommend the prescription drug, Depakote, to nursing home physicians. Notably, while the Omnicare-employed consultant pharmacists reviewed nursing home residents’ medical charts and made recommendations about what drugs should be prescribed, the ultimate decision remained with the nursing home physician.

The government is interested in pursuing similar cases. With nursing homes, health systems, and provider groups increasingly seeking the advice of various consultants, people are encouraged to step forward to expose consultants who exchange recommendations for kickbacks. In the nursing home context, perhaps Principal Deputy Assistant Attorney General Benjamin C. Mizer, head of the Department of Justice’s Civil Division, said it best:

Kickbacks to entities making drug recommendations compromise their independence and undermine their role in protecting nursing home residents from the use of unnecessary drugs.

More information for whistleblowers is located at the Nolan Auerbach & White website.

The post Anti-Kickback Statute Reaches Consultants Who Seek to Improperly Influence Healthcare Providers appeared first on Medicare Fraud 101.

While the 60-day time limit has been on the books for over seven years, the Justice Department has shown little interest in going after providers who repay identified overpayments after sixty days. Indeed, the case against Mount Sinai is the only qui tam case raising such allegations where the government has filed a notice of intervention.

In this tide-turning case, U.S. ex rel. Kane v. Healthfirst, Inc. et al. (SDNY), the Government alleged in its Complaint-in-intervention that certain New York hospitals failed to refund Medicaid overpayments within 60 days of identifying them. According to the Complaint, beginning in 2009, the New York Department of Health Comptroller’s Office allegedly made an inquiry of Defendants regarding a small number of claims that were erroneously submitted for reimbursement.  As a result of the inquiry, Defendants undertook an internal investigation to determine the reasons for the improper claims and the scope of the problem.  By 2011, Defendants had allegedly identified more than 900 claims erroneously submitted to Medicaid, leading to over $1 million wrongfully paid by Medicaid as a secondary payor.  According to the Government’s Complaint, Defendants allegedly delayed repaying the majority of these claims for more than two years and that repayments were made only after further pressing by the Comptroller’s Office.

Hopefully, this recovery sends a message to healthcare providers that they can no longer sit on improper payments. If they make this wayward decision, Congress has empowered the Government to pay substantial rewards to qui tam relators who step forward and bring a successful action. If the Government is unable or unwilling to move forward with these cases, relators can.

More information for whistleblowers is located at the Nolan Auerbach & White website.

The post Government Recovers Millions from Hospital System that Allegedly Wrongfully Retained Medicaid Overpayments for Over 60 Days appeared first on Medicare Fraud 101.

So what is driving this tremendous in-office growth? Given the sizeable year-over-year jump in procedures, False Claims Act (FCA) violations might be a part of the equation. Specifically, providers could be running afoul of the FCA if the tests that are not medically reasonable and necessary for the care of Medicare patients.

Moreover, if the medical device manufacturers are deploying marketing tactics that are causing medically unnecessary in-office tests, they too could run afoul of the False Claims Act. In fact, a similar FCA causation theory was used to hold Kyphon liable for allegedly causing providers to use the manufacturer’s kyphoplasty devices in an improper setting. Subsequent to this settlement, hundreds of hospitals inked settlement checks because they allegedly followed Kyphon’s improper marketing advice.

Simply put, given the tremendous whistleblower rewards available under the FCA, healthcare providers should be on the lookout for improper marketing tactics pushing medically unnecessary in-office tests.

More information for potential whistleblowers is located at the Nolan Auerbach & White website.

The post Are Medically Unnecessary Tests Driving Growth of In-Office Procedures? appeared first on Medicare Fraud 101.

The concern is that pharmaceutical companies may be using these organizations to illegally funnel kickbacks to beneficiaries. This became a heightened concern since 2006, when the Medicare Part D coverage gap (or so-called “Medicare donut hole”) required beneficiaries to come out of pocket for drug costs after they reached the initial coverage limit and until they reached the catastrophic-coverage threshold. This temporal “donut hole” can costs drug beneficiaries thousands of dollars per year.

However, HHS-OIG has repeatedly stressed that donations to these organizations from pharmaceutical manufacturers are not per se violations of the federal Anti-Kickback Statute (AKS). Instead, through various Advisory Opinions, HHS-OIG has announced various factors that must exist to shield the donor-pharmaceutical manufacturers and the recipient-organizations from AKS liability.

For example, in a 2015 Advisory Opinion, HHS-OIG stressed that the organization must be an “independent, bona fide charitable assistance program.” HHS-OIG stated that such an “interposition” between patients and pharmaceutical manufacturers should “provide sufficient insulation so that the [organization’s] assistance to patients should not be attributed to any of its Donors.”

With the assistance of inside employees, the government will look behind the supposed “independent” façade of some of these charitable assistance programs, ultimately finding, we predict, outliers with culpable conduct.

More information for whistleblowers is located at the Nolan Auerbach & White website.

The post Are Copayment Assistance Nonprofits to Funneling Kickbacks to Patients? appeared first on Medicare Fraud 101.

• criticize Emergency Department doctors and demand their termination if they were passing up opportunities to cause the admission of Medicare beneficiaries;
• request increased work schedules for Emergency Department doctors whose patients had a relatively high rate of admission;
• request decreased or discontinued work schedules for Emergency Department doctors whose patients had a relatively low rate of admission;
• tell Emergency Department doctors to find a way to admit all patients over 65 because they all have insurance; and
• tell Emergency Department doctors that an insured patient who would be in the Emergency Department for more than two hours waiting for test results should be admitted, but an uninsured patient could stay in the ED for 6 to 8 hours awaiting results and then be discharged.

Emergency Department physicians and directors of case management are in the best position to evidence such wrongdoing. For these individuals, substantial whistleblower rewards might be available.

More information for potential whistleblowers is located at the Nolan Auerbach & White website.

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