Category Archives: Medicare Fraud

CMS Fights Medicare Fraud With Ban on New Home Health Agencies and Ambulance Suppliers in Three Cities

LOL Blog Label 2

By Lance O. Leider, J.D., The Health Law Firm and George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

The Centers for Medicare and Medicaid Services (CMS) announced it will temporarily ban new home health providers and ambulance suppliers from enrolling in Medicare, Medicaid and the Children’s Health Insurance Program (CHIP) in three fraud “hot spots.” According to CMS, the six-month moratorium begins July 30, 2013. It applies to newly enrolling home health agencies (HHAs) in Miami, Florida, and Chicago, Illinois. It also applies to newly enrolling ambulance suppliers in Houston, Texas. Existing providers and suppliers can continue to deliver and bill for services. The goal of the ban is to fight healthcare fraud.

Click here to read the press release from CMS.

Authority to impose a moratorium was included in the Patient Protection and Affordable Care Act (PPACA). According to a summary of the anti-fraud provisions in the Affordable Care Act, the Act allows CMS to prohibit new providers from joining the program where necessary to prevent or fight fraud, waste or abuse in certain geographic areas or for certain categories of services. This is the first time CMS is exercising its authority.

Why Moratorium Was Imposed in These Areas.

According to CMS, the decision to impose the moratorium was based on a number of factors, including a disproportional number of providers and suppliers relative to beneficiaries, a quick increase in enrollment applications from providers and suppliers, and extremely high utilization in these areas.

Miami Area a Hot Bed for Healthcare Fraud and Abuse.

The Miami area has stood out as one of the nation’s hubs of Medicare fraud, according to CMS. For example, in May 2013, a Miami patient recruiter for an HHA was sentenced to 37 months in prison for participating in a $20 million Medicare fraud scheme. Click here to read a previous blog. In that same month, workers from a Miami-area HHA were accused of bribing Medicare beneficiaries for their Medicare information, which was used to bill for home health services that were never rendered or not medically necessary. To read more, click here.

According to the Miami Herald, with a large number of elderly Medicare beneficiaries living in Miami, it’s not a surprise that healthcare fraud is so prevalent. South Florida allegedly accounts for one-third (1/3) of all healthcare fraud prosecutions in the nation. Click here to read the entire Miami Herald article.

The Affordable Care Act Offers the Government New Tools to Fight Healthcare Fraud.

In 2011 and 2012, the government reported recovery of $14.9 billion in healthcare fraud judgments, settlements and administrative impositions, according to CMS. In addition, CMS has revoked 14,663 providers and suppliers’ ability to bill the Medicare Program since 2011. The Affordable Care Act seeks to improve anti-fraud and abuse measures by focusing on prevention rather than the traditional “pay-and-chase” model of catching crooks after they have committed fraud. Click here to read a blog on the Affordable Care Act’s other fraud fighting tools.

What This Means for Health Care Professionals and Providers.

By knowing the government is beefing up measures to fight healthcare fraud, providers can attempt to avoid practices that are likely to lead to Zone Program Integrity Contractor (ZPIC) or Recovery Audit Contractor (RAC) audits. Additionally, a provider can be prepared for potential audits by increasing its documentation and compliance efforts.

Don’t Wait Until It’s Too Late; Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now.

The attorneys of The Health Law Firm represent healthcare providers in Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S. They also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.
For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or (850) 439-1001.

Comments?

What do you think of CMS’ decision to invoke the moratorium? Do you think this should have been done sooner? Please leave any thoughtful comments below.

Sources:

Centers for Medicare and Medicaid Services. “CMS Imposes First Affordable Care Act Enrollment Moratoria to Combat Fraud.” CMS.gov. (July 26, 2013). From: http://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-Releases/2013-Press-Releases-Items/2013-07-26.html

Chang, Daniel. “Feds Ban New Home Healthcare Agencies in Miami to Fight Medicare Fraud.” Miami Herald. (July 26, 2013). From: http://www.miamiherald.com/2013/07/26/3524612/feds-ban-new-home-healthcare-agencies.html

Beasley, Deena. “U.S. Bans New Home Health, Ambulance Providers in Three Regions.” Miami Herald. (July 26, 2013). From: http://www.reuters.com/article/2013/07/26/us-medicare-moratoria-idUSBRE96P14P20130726

About the Authors: Lance O. Leider is an attorney with The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Avenue, Altamonte Springs, Florida 32714, Phone: (407) 331-6620.

George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

 

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
Copyright © 1996-2012 The Health Law Firm. All rights reserved.

Fifty-Five Hospitals Around the Country to Pay the Government $34 Million Settlement for False Claims Allegations

10 Indest-2008-7By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

Fifty-five (55) hospitals in twenty-one (21) states have agreed to pay the Department of Justice (DOJ) more than $34 million to settle allegations of Medicare fraud in a whistleblower case, according to the DOJ on July 2, 2013. The false claims allegations involve a back procedure called a kyphoplasty. The kyphoplasty can be performed safely and effectively as an outpatient procedure. However, it is alleged that hospitals were using more expensive, inpatient procedures to increase Medicare billings.

To read the press release from the DOJ, click here.

A kyphoplasty is used to treat spinal fractures usually caused by osteoporosis.

Fourteen (14) Florida Hospitals to Pay $11 Million to Government.

According to an article on Health News Florida, fourteen (14) Florida hospitals have agreed to pay around $11 million to settle the DOJ’s false claims charges.

One of the Florida hospitals was Mount Sinai Medical Center in Miami, which will pay $1.84 million. A number of HCA hospitals in Florida were included in the settlement. These hospitals will pay $7.14 million collectively. Another group that settled was the hospitals in the Morton Plant Mease group, which is part of the Baycare Health System in Tampa Bay. This settlement was listed at $2.37 million.

To see all of the Florida hospitals allegedly involved, click here to read the Health News Florida article.

Whistleblower Lawsuit Filed by Two Former Employees.

According to the DOJ, all but four of the settling facilities were named as defendants in a whistleblower lawsuit brought under the False Claims Act. The lawsuits were filed by a former reimbursement manager for Kyphon and a former regional sales manager for Kyphon. The DOJ stated that Kyphon is the company that allegedly advised hospitals to do kyphoplasty procedures as inpatient instead of outpatient procedures. These two will receive a total of about $5.5 million from the settlements.

If you want to know more about whistleblower/qui tam lawsuits, click here to read the first part of a two-part blog, and click here for the second part.

Previous Settlements from Kyphoplasty Procedures.

A similar settlement was reached in 2012, when 14 hospitals agreed to pay a settlement of more than $12 million to the government for allegedly inflating their profits based on unnecessary hospital admissions, according to the Washington Post. Click here to read that article.

The DOJ stated that it has now reached settlements with more than 100 hospitals, for a total of about $75 million resolving allegations that the facilities fraudulently billed Medicare for kyphoplasty procedures.

The Health Care Fraud Prevention and Enforcement Action Team (HEAT) is on Fire.

These settlements are a part of the government’s fight against health care fraud and another win for the Health Care Fraud Prevention and Enforcement Action Team (HEAT). HEAT’s mission is to focus its efforts on preventing and deterring fraud and to enforce current anti-fraud laws around the country. It was created in 2009, by the Department of Health and Humans Services (HHS) and the DOJ. To date, the DOJ’s total recoveries in False Claims Act cases since January 2009, are more than $14.7 billion. To learn more about HEAT, click here.

Contact Health Law Attorneys Experienced with Qui Tam or Whistleblower Cases.

Attorneys with The Health Law Firm also represent health care professionals and health facilities in qui tam or whistleblower cases. We have developed relationships with recognized experts in health care accounting, health care financing, utilization review, medical review, filling, coding, and other services that assist us in such matters.

To contact The Health Law Firm, please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.

Comments?

What do you think of these settlements? Please leave any thoughtful comments below.

Sources:

Department of Justice. “Fifty-Five Hospitals to Pay U.S. More Than $34 Million to Resolve False Claims Act Allegations Related to Kyphoplasty.” Department of Justice. (July 2, 2013). From: http://www.justice.gov/opa/pr/2013/July/13-civ-745.html

Associated Press. “Justice Department, 55 Hospitals Reach $34 Million Settlement Over Medicare Fraud Claims.” Washington Post. (July 2, 2013). From: http://www.washingtonpost.com/business/justice-department-55-hospitals-reach-34-million-settlement-over-medicare-fraud-claims/2013/07/02/3d3d2356-e34e-11e2-bffd-37a36ddab820_story.html

Health News Florida Staff. “14 FL Hospitals to Pay $11 Million.” Health News Florida. (July 2, 2013). From: http://health.wusf.usf.edu/post/14-fl-hospitals-pay-11-million

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board
Certified by The Florida Bar in Health Law.  He is the President and Managing Partner of The Health Law Firm, which has a national practice.  Its main office is in the Orlando, Florida, area.  www.TheHealthLawFirm.com  The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone:  (407) 331-6620.

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
Copyright © 1996-2012 The Health Law Firm. All rights reserved.

Health Care Professionals and Providers Beware: The Health Care Fraud Prevention and Enforcement Action Team (HEAT) Is Catching Fire

8 Indest-2008-5By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

In May 2009, the Department of Health and Humans Services (HHS) and the Department of Justice (DOJ) created the Health Care Fraud Prevention and Enforcement Action Team (HEAT). HEAT’s mission is to focus its efforts on preventing and deterring fraud and to enforce current anti-fraud laws around the country. To date, almost 1,400 individuals have been charged in connection with schemes involving more than $4.8 billion in fraudulent billings in these HEAT takedown operations.

To learn more about HEAT, click here to visit the website.

The Success of the HEAT Team.

According to the website, between 2008 and 2011, HEAT actions led to a seventy-five percent (75%) increase in individuals charged with criminal health care fraud. So far there have been six nationwide HEAT sting operations.

In 2011, HEAT agents led the largest-ever federal health care fraud takedown involving $530 million in fraudulent billing. To read more on this sting, click here.

On May 14, 2013, the DOJ announced that more than 400 law enforcement officials with HEAT spread out between eight cities including Miami and Tampa Bay to arrest 89 people accused of false billing. A majority of these arrests were allegedly of health care professionals. Click here to read a blog with more information on this takedown.

HEAT Captures One of Medicare’s Most-Wanted Fugitives.

On June 1, 2013, a former Los Angeles physical therapy clinic owner, and one of Medicare’s most-wanted fugitives, was arrested by HEAT agents at the Los Angeles International Airport on his return flight. According to a Los Angeles Times article, the clinic owner was an acupuncturist who billed Medicare for $2.1 million in false claims and was paid about $1.2 million. To read more from the Los Angeles Times, click here.

Expanding the Medicare Fraud Strike Force Efforts.

HEAT is a multi-agency team of federal, state and local investigators who combat Medicare fraud through the use of Medicare data analysis techniques and an increased focus on community policing.

The Affordable Care Act has given HEAT additional tools to preserve Medicare by expanding the team’s authority to suspend Medicare payments and reimbursements when fraud is suspected.

To better combat fraud, the government has established HEAT in a number of cities, such as Los Angeles, Miami, Tampa Bay, Houston, Dallas, Chicago, Brooklyn, Baton Rouge and Detroit.

Don’t Wait Until It’s Too Late; Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now.

The attorneys of The Health Law Firm represent health care providers in Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S. They also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.

For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or (850) 439-1001.

Comments?

Have you heard of HEAT? Do you think the team’s efforts are curbing Medicare fraud around the country? Please leave any thoughtful comments below.

Sources:

Department of Justice. “Medicare Fraud Strike Force Charges 89 Individuals for Approximately $223 Million in False Billing.” Department of Justice. (May 14, 2013). From: http://www.justice.gov/opa/pr/2013/May/13-crm-553.html

Terhune, Chad. “One of Medicare’s Most-Wanted Fugitives is Arrested in L.A.” Los Angeles Times. (June 3, 2013). From: http://www.latimes.com/business/money/la-fi-mo-medicare-most-wanted-fugitive-arrest-20130603,0,7474342.story

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
Copyright © 1996-2012 The Health Law Firm. All rights reserved.

Department of Justice Seeks up to $600 Million in Whistleblower Case Against Halifax Health in Daytona Beach, Florida

1 Indest-2008-1By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

The U.S. Department of Justice (DOJ) is asking for between $350 million and $600 million in damages and penalties from Halifax Health Medical Center in Daytona Beach, according to The Daytona Beach News-Journal. A Halifax employee filed the whistleblower lawsuit in 2009, accusing the hospital of illegal kickbacks to doctors, improper admissions and unnecessary spinal surgeries. The DOJ joined the case in 2011. Click here to read a previous blog on the DOJ joining the lawsuit.

If the government wins this case, it would amount to the largest whistleblower case of its kind in the nation.

Claims Against Halifax.

Halifax is accused of overbilling Medicare by inappropriately admitting patients and having financial arrangements with some of its doctors that violated a federal anti-kickback law.

The federal Stark Law prohibits Medicare and Medicaid payments for hospital services that are prescribed by doctors who have profit-sharing agreements with the hospital. The law was made to ensure that referrals are made for medical reasons only, without financial motives. However, according to the lawsuit, Halifax had agreements with its doctors that gave them a financial incentive to generate hospital revenues.

The whistleblower was recently interviewed in an Orlando Sentinel article. She claims neurosurgeons at Halifax allegedly received illegal kickbacks tied to their performance. The whistleblower claims a similar pattern existed with six of the hospital’s oncologists. The suit also alleges one surgeon performed spinal fusion surgeries that were not medically necessary.

To read more from the whistleblower in an Orlando Sentinel article, click here.

Halifax Denies All Claims.

Halifax denies all of the DOJ’s allegations. The hospital has filed two motions to dismiss the case. However, both have been denied. According to The Daytona Beach News-Journal, the case is set for trial in November 2013. Click here to read the entire article from The Daytona Beach News-Journal.

Whistleblowers Who Report Fraud and False Claims Against the Government Stand to Receive Large Rewards.

Since the Halifax whistleblower filed her action under a federal law, she is entitled to recoup fifteen percent (15%) to twenty-five percent (25%) of the damages. Similarly, individuals working in the health care industry, whether for hospitals, nursing homes, medical groups, home health agencies or others, often become aware of questionable activities. Often they are even asked to participate in it. In many cases the activity may amount to fraud on the government.

In a two-part blog, I explain types of false claims, the reward programs for coming forward with a false claim, who can file a whistleblower/qui tam lawsuit and what is needed to be a successful whistleblower. Click here for part one, and click here for part two.

Contact Health Law Attorneys Experienced with Medicaid and Medicare Qui Tam or Whistleblower Cases.

In addition to our other experience in Medicare, Medicaid and Tricare cases, attorneys with The Health Law Firm also represent health care professionals and health facilities in qui tam or whistleblower cases. We have developed relationships with recognized experts in health care accounting, health care financing, utilization review, medical review, filling, coding, and other services that assist us in such matters.

To learn more on our experience with Medicaid and Medicare quit tam or whistleblower cases, visit our website.

To contact The Health Law Firm, please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.

Comments?

What do you think of this qui tam/whistleblower lawsuit? Please leave any thoughtful comments below.

Sources:

Swisher, Skyler. “Justice Department Seeks up to $600 Million in Lawsuit Against Halifax.” The Daytona Beach News Journal. (June 3, 2013). From: http://www.news-journalonline.com/article/20130603/NEWS/306039975/1040?p=1&tc=pg

Jameson, Marni. “Halifax Hospial Whistleblower at Forefront of $200M Alleged Fraud.” Orlando Sentinel. (April 15, 2013). From: http://articles.orlandosentinel.com/2013-04-15/news/os-halifax-hospital-whistleblower-20130415_1_marlan-wilbanks-illegal-kickbacks-halifax-health

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

 

 

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
Copyright © 1996-2012 The Health Law Firm. All rights reserved.

The Affordable Care Act Offers the Government New Tools to Fight Healthcare Fraud

By Catherine T. Hollis, J.D., The Health Law Firm

In 2013, the government reported recovery of a record-breaking $10.7 billion in healthcare fraud in the past three years, according to the U.S. Department of Health and Human Services (HHS) and the U.S. Department of Justice (DOJ). The HHS credits the Affordable Care Act’s tough stance on fraud for improving the efforts to fight Medicare fraud.

The increase in fraud recovery is attributed in part to the Act’s proactive approach to preventing fraud. The Act contains several initiatives that address Medicare fraud, resulting in increased fraud-fighting tools available to the government. The joint effort between the HHS, the DOJ and the Health Care Fraud Prevention and Enforcement Action Team has been a primary driving force in seeking out fraud and securing recoveries. The HHS and DOJ’s website highlights some of the Act’s “powerful steps” toward fighting fraud, waste and abuse. Click here to read more from www.stopmedicarefraud.gov.

Tougher Punishment.

The Act increases federal sentencing guidelines for healthcare fraud by twenty percent (20%) to fifty percent (50%) for crimes that involve more than $1 million in losses. The Act also establishes penalties for obstructing a fraud investigation or an audit.

Stricter Screening for Enrollment and Revalidation.

According to the HHS, the new screening procedures include licensure checks and site visits for all providers and suppliers. In addition, the Act imposes higher scrutiny on providers and suppliers who may pose a higher risk of fraud or abuse. High risk providers and suppliers can be subject to unscheduled site visits and fingerprint-based criminal background checks.

The Center for Medicare & Medicaid Services (CMS) has started to revalidate the enrollment of all 1.5 million existing Medicare providers and suppliers, using the new screening requirements set forth by the Act. Thousands of enrollments have already been deactivated or revoked as the result of this effort. There is a blog on our website about the devastating and far reaching effects of being excluded from the Medicare program. Click here to read that blog.

New Detection Technology.

CMS is using the Fraud Prevention System to screen all fee-for-service Medicare claims. This system uses advanced predictive technology, similar to that used by credit card companies, to analyze claims prior to payment. It also scans for suspicious billing patterns. Claims identified by the Fraud Prevention System as suspect are reviewed by CMS for possible fraud.

Increased Resources.

The Act provides an additional $350 million over ten years (2011 through 2020) through the Health Care Fraud and Abuse Control Account.

These steps represent a more proactive approach to Medicare fraud. The government is focusing on preventing fraud before it happens, rather than paying fraudulent claims and seeking reimbursement after the fact. The tools contained in the Act, as implemented by CMS and HHS, further the goal of the Act to reduce fraud, waste and abuse in the Medicare system. To read a summary of the anti-fraud provisions in the Affordable Care Act, click here.

Anti-Fraud Provisions At Work.

On May 14, 2013, the HHS and DOJ announced the arrest of 89 people, including doctors, nurses and other medical professionals, in eight cities. These people are allegedly charged in separate Medicare fraud schemes. According to the DOJ, the scans involve approximately $223 million in false billing. Click here to read a blog on these arrests. To read more blogs on Medicare and Medicaid fraud, visit our website.

Don’t Wait Until It’s Too Late; Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now.

The attorneys of The Health Law Firm represent healthcare providers in Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S. They also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.

For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or (850) 439-1001.

Comments?

Do you think the Affordable Care Act will help cut down on healthcare fraud? Why or why not? Please leave any thoughtful comments below.

Sources:

Sjoerdsma, Donald. “The Affordable Care Act Bolstered, Didn’t Drive Medicare Anti-Fraud Efforts.” The Medicare Newsgroup. (March 22, 2013). From: http://medicarenewsgroup.com/context/understanding-medicare-blog/understanding-medicare-blog/2013/03/22/the-affordable-care-act-bolstered-didn-t-drive-medicare-anti-fraud-efforts

“The Affordable Care Act and Fighting Fraud.” U.S. Department of Health & Human Services and U.S. Department of Justice. From: http://www.stopmedicarefraud.gov/aboutfraud/aca-fraud/index.html

 

Health Benefits ABCs. “Summary of Anti-Fraud Provisions in the Affordable Care Act.” U.S. Administration on Aging, Department of Health and Human Services. From: http://www.smpresource.org/Content/NavigationMenu/ConsumerProtection/HealthCareReform/Anti-Fraud_Provisions_in_Health_Care_Reform.docx

“New Tools to Fight Fraud, Strengthen Federal and Private Health Programs, and Protect Consumer and Taxpayer Dollars.” U.S. Department of Health & Human Services. (March 15, 2011). From: http://www.healthcare.gov/news/factsheets/2011/03/fraud03152011a.html

About the Author: Catherine T. Hollis is an attorney with The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Avenue, Altamonte Springs, Florida 32714, Phone: (407) 331-6620.

 

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
Copyright © 1996-2012 The Health Law Firm. All rights reserved.

Strike Force Busts 89 People, Mostly Health Care Professionals, in Nationwide Crackdown on Medicare Fraud

8 Indest-2008-5By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

In a nationwide takedown nearly 100 people, including doctors, nurses and other medical professionals, in eight cities were all allegedly charged in separate Medicare fraud schemes. These individual scams involved approximately $223 million in false billing, according to the Department of Justice (DOJ) and the Department of Health and Humans Services (DHHS). On May 14, 2013, more than 400 law enforcement officials with the Medicare Fraud Strike Force spread out between Miami, Detroit, Los Angeles, New York, New Orleans, Houston, Chicago and Tampa to make the arrests of these 89 people, according to the DOJ.

Click here to read the press release from the DOJ.

Medicare Schemes Could Not Have Happened Without the Help of Health Professionals.

According to an article in Reuters, one out of every four defendants in this crackdown was some type of health professional. Authorities say most of these allegedly complex scams could not have happened without the participation of a doctor signing off on a bogus service, or a nurse filling out false paperwork.

Click here to read the entire article from Reuters.

Florida Health Professionals Involved.

According to the DOJ, in Miami, a total of 25 people, including two nurses and a paramedic, were allegedly part of numerous Medicare scams, totaling about $44 million in false claims. In one case involving a home health agency, defendants allegedly bribed Medicare beneficiaries for their Medicare information, which was used to bill for home health services that were never rendered or not medically necessary. The DOJ believes the lead defendant spent a majority of the money from the scam on luxury cars.

Phony Health Care Clinics Set Up.

In Tampa, nine individuals were charged in a variety of schemes, ranging from pharmacy fraud to health-care related money laundering. According to the DOJ, in one case four individuals allegedly established four health care clinics. The individuals allegedly used these clinics to steal more than $2.5 million from Medicare for surgical procedures that were never performed.

This Marks the Sixth Time the Medicare Fraud Strike Force Has Executed a Nationwide Crackdown.

This crackdown marks the sixth time the Medicare Fraud Strike Force has taken nationwide action against Medicare fraud. To date, the Medicare Fraud Strike Force is credited with making more than 1,500 arrests on charges related to $5 billion in allegedly false Medicare claims since 2007. According to the DOJ, it’s believed Medicare fraud costs the program between $60 billion and $90 billion each year.

Medicare operates under a pay-and-chase system, but according to the Washington Post, authorities are beginning to use new technology that flags suspicious claims before Medicare makes a payment. To read the entire Washington Post article, click here.

Don’t Wait Until It’s Too Late; Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now.

The attorneys of The Health Law Firm represent health care providers in Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S. They also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.

For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or (850) 439-1001.

Comments?

What do you think of these nationwide crackdowns on Medicare fraud? Do you think they work as a deterrent for others committing health care fraud? Please leave any thoughtful comments below.

Sources:

Department of Justice. “Medicare Strike Force Charges 89 Individuals for Approximately $223 Million in False Billing.” Department of Justice. (May 14, 2013). From: http://www.justice.gov/opa/pr/2013/May/13-crm-553.html

Kennedy, Kelli. “Doctors and Nurses Among Nearly 100 Charged in $223 Million Medicare Fraud Busts in 8 Cities.” Washington Post. (May 14, 2013). From: http://www.washingtonpost.com/politics/health_care/doctors-nurses-among-nearly-100-charged-in-223-million-medicare-fraud-busts-in-8-cities/2013/05/14/fbb0de3a-bcbc-11e2-b537-ab47f0325f7c_story.html

Morgan, David. “U.S. Charges 89 People in $223 Million Medicare Fraud Scheme.” Reuters. (May 14, 2013). From: http://www.reuters.com/article/2013/05/14/usa-healthcare-fraud-idUSL2N0DV3GZ20130514

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

 

The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
Copyright © 1996-2012 The Health Law Firm. All rights reserved.

Two Separate Lawsuits Against Novartis Pharmaceuticals Corporation Allege Illegal Kickbacks and False Claims

IndestBy George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

Novartis Pharmaceuticals Corporation (NPC) is currently fielding two different lawsuits, filed just days apart from each other, by the U.S. Department of Justice (DOJ). The first lawsuit was filed on April 23, 2013, alleging the company gave illegal kickbacks to pharmacists. A second lawsuit was filed on April 26, 2013, alleging illegal kickbacks were paid by NPC to health care providers. According to the DOJ, the government’s complaint seeks damages and civil penalties under the False Claims Act, and under the common law for paying kickbacks to doctors to induce them to prescribe NPC products that were reimbursed by federal health care programs.

Click here to read the entire press release from the DOJ.

NPC Accused of Treating Health Care Professionals to Expensive Dinners, Product Discounts and Fishing Trips.

Both lawsuits allege NPC violated the Anti-Kickback Statute. In the April 23, 2013, complaint against NPC the lawsuit alleges the company gave kickbacks, in the form of rebates and discounts to pharmacies in exchange for the pharmacies’ cooperation in switching patients from competitors’ drugs to NPC products.

The April 26, 2013, lawsuit accuses NPC of paying doctors to speak about certain drugs at events that were allegedly social occasions. Many of the programs were allegedly held in circumstances in which it would be impossible to have a presentation. According to the DOJ, this included fishing trips off the Florida coast and meetings in Hooters restaurants. NPC is also accused of treating health care professionals to expensive dinners. The payments and dinners were apparently kickbacks to the doctors for writing prescriptions for NPC drugs.

Florida Doctors Involved.

The lawsuit alleges at least six Florida doctors of participating in the bogus conferences and taking thousands of dollars in kickbacks, according to the Tampa Bay Times. The doctors are not named or charged in the civil lawsuit.

To read the allegations listed in the lawsuit against Florida doctors, click here for the Tampa Bay Times article.

NPC Denies All Claims.

In a press release, NPC disputes all of the government’s allegations. The pharmaceutical company states that discounts and rebates by pharmaceutical companies are a customary and legal procedure, as recognized by the government. It also addresses the physician speaker programs by saying the programs are also acceptable practices designed to inform physicians about the uses of different types of medicines. Click here to read the entire press release from NPC.

The Law Against Using Bribes in Exchange for Selling a Drug or Service.

For years drug companies have paid doctors to speak about new drugs at educational conferences with other health care professionals. The practice is legal, but considered questionable.

Under the Anti-Kickback Statute, it’s a felony for health care professionals to accept bribes in exchange for recommending a drug or service covered by Medicare, Medicaid, TRICARE or the Department of Veterans Affairs health care program.

Whistleblowers Who Report Fraud and False Claims Against the Government Stand to Receive Large Rewards.

The original complaint against NPC was allegedly filed under the qui tam, or whistleblower, provisions of the False Claims Act by a former sales representative.

Individuals working in the health care industry, whether for hospitals, pharmacies, nursing homes, medical groups, home health agencies or others, often become aware of questionable activities. Often they are even asked to participate in it. In many cases the activity may amount to fraud on the government.

In a two-part blog series on whistleblower/qui tam lawsuits I explain types of false claims, the reward programs for coming forward with a false claim, who can file a whistleblower/qui tam lawsuit, and more. Click here to read the first part of this blog, and click here for the second part.

Contact Health Law Attorneys Experienced with Qui Tam or Whistleblower Cases.

Attorneys with The Health Law Firm represent plaintiffs, patients, health care professionals and health facilities in qui tam or whistleblower cases. We have developed relationships with recognized experts in health care accounting, health care financing, utilization review, medical review, filling, coding, and other services that assist us in such matters.

To contact The Health Law Firm, please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.

Comments?

What do you think of these lawsuits? Please leave any thoughtful comments below.

Sources:

Masow, Julie. “Novartis Pharmaceuticals Corporation Disputes Allegations in Two US Government Lawsuits and Looks Forward to a Fair Discussion of the Facts.” Novartis Pharmaceuticals. (April 26, 2013). From: http://www.pharma.us.novartis.com/newsroom/pressreleases/137176.shtml

Davis, Brittany Alana. “Lawsuit: Pharmaceutical Company Gave Kickbacks to Florida Doctors.” Tampa Bay Times. (May 3, 2013). From: http://www.tampabay.com/news/courts/lawsuit-pharmaceutical-company-gave-kickbacks-to-florida-doctors/2119133

Department of Justice. “United States Files Complaint Against Novartis Pharmaceuticals Corp. for Allegedly Paying Kickbacks to Doctors in Exchange for Prescribing Its Drugs.” Department of Justice. (April 26, 2013). From: http://www.justice.gov/opa/pr/2013/April/13-civ-481.html

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

 

The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
Copyright © 1996-2012 The Health Law Firm. All rights reserved.