Articles Posted in Medicare Fraud

The country’s taxpayer-funded healthcare plans – Medicare, Medicaid and TRICARE – provide important benefits to our aging citizens, our economically disadvantaged and our combat veterans that is necessary for millions to survive. However, greed coerces many bad actors to commit acts of fraud each year that cost taxpayers billions of dollars and undermine the crucial system. If you have any reason to believe you were used as part of a Medicare fraud scheme, or have any information about one, contact the Cambridge white collar crime experts at Altman & Altman LLP today.

How does Medicare fraud happen?

With a system as large and complex as Medicare, it guarantees that there will be opportunities for morally-bankrupt doctors, nurses, beneficiaries and others in the healthcare field to take advantage of weaknesses in that system. There is an entire branch of the Office of the Inspector General responsible for investigating and rooting our Medicare fraud.

While no case of Medicare fraud can ever be identical, there are certainly common threads between acts of Medicare fraud. Often they involve one or multiple of the following elements:

  • Overbilling for services
  • Billing for services multiple times
  • Fraudulent billing using falsified patient information or information obtained illegally
  • Billing for services never rendered
  • Falsifying medical diagnoses and charging for their treatment
  • Kickback schemes to secure illicit referrals of patients
  • Prescribing unnecessary medication

A recent 2017 bust of a comprehensive Medicare fraud scheme revealed a $1.3 billion operation that spanned 41 federal districts and involved 412 individuals, including 115 medical doctors, nurses and other medical personnel. It was the largest Medicare fraud bust in the country’s history, and revealed a lot about the extent of Medicare fraud in the country.

The gist of this comprehensive scheme, actually, was quite simple. Medical doctors billed Medicare for services that were never rendered, for prescriptions that were never ordered, and individuals paid kickbacks (incentivized bribes) for beneficiary information so that they could be used as “patients” for fraudulent charges to Medicare that never occurred. Get enough people involved in the scheme and it becomes a billion-dollar operation born from a lack of morality and an abundance of greed.

Fraudulent billing to Medicare is not only illegal, it is incredibly unethical, as it drives medical costs up for everybody else as a result and can leave those who have had their information shared unbeknownst to them vulnerable to identify theft and other financial crimes. Continue reading

In the past, the primary whistle blower act in place has been the Federal False Claims Act, which was enacted during the Civil War to combat fraud against the federal government by suppliers to the Union Army.  Also commonly called “Lincoln’s Law”, the False Claims Act was rarely used until it was completely overhauled in 1986.  The 1986 amendments were prompted by publicized reports of abuses in the defense contracting industry, in which the government was being exponentially overcharged for household items.  During the revamp, more financial incentives were put into place and barriers to actions against those who allegedly submitted false claims to the government were reduced.  Since the new 1986 amendments were passed, the False Claims Act has become the government’s most effective and successful tool in combating unneeded or fraudulent federal spending.

From 1986 to 2015, this Act has retrieved over $48 billion as an outcome of cases filed under Lincoln’s Act.  Although this Act proved to be quite successful with federal fraud, it cannot pursue cases of financial fraud that do not involve the government.  The Act does not protect against those who blow the whistle against financial companies or corporations unless the federal government is somehow also experiencing some financial loss.  With the Great Recession, came ample motive to enact a new law protecting whistle blowers of financial institutions.

In 2010, shortly after the housing bubble burst, the Dodd-Frank Wall Street Reform and Consumer Protection Act was passed.  This act was implemented to prevent any future reckless financial behavior as well as to incite, reward, and protect whistle blowers.  This act protects those who can provide novel insider evidence of financial fraud to the Securities and Exchange Commission (SEC) and the Commodity Futures Trading Commission.  If a whistle blower, also called a relator, brings original insider information forward and the agency can successfully have a suit against the accused, the relator can potentially receive 10 to 30 percent of the total fines the accused is charged with.  In addition to this financial incentive, the Dodd-Frank Act also protects whistle blowers from those trying to retaliate, such as the whistle blower’s boss or company.  The Act allows the relator to take those seeking retaliation to court.  The overall success of the False Claims Act has been due to the whistle blowers responding to the qui tam provisions of the Act.  These provisions essentially allow any person to file a case on the behalf of the federal government.  Qui tam provisions make it easier to sift through false claims made to the government.  Continue reading

Rosseau Management Inc. will pay $300,000 to resolve a Medicare billing fraud lawsuit accusing the assisted living facilities owner of letting subcontractor RehabCare Group East. Inc. turn in fraudulent Medicare claims. The latter provided rehabilitation therapy at three facilities.

According to the Department of Justice’s U.S. Attorney’s Office in the District of Massachusetts, previous to October 2011, Rosseau did not take the necessary steps to stop RehabCare from providing high levels of therapy that were unreasonable or unnecessary during “assessment reference periods.” This caused the assisted living facilities to bill for care for their Medicare patients at the highest levels of reimbursement. During other times when assessment wasn’t a factor, RehabCare gave these same patients less therapy.

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The Justice Department is now part of two whistleblower lawsuits accusing cardiologist Asad Qamar and his Institute for Cardiovascular Excellence of Medicare fraud. The complaints contend that Qamar conducted and billed for peripheral artery intervention procedures that were not necessary and waived 20% co-payments so that patients wouldn’t question his recommendations for treatment. The plaintiffs are treating the waived copayments as kickbacks that were made to patients.

According to Medicare payment data released last April, in 2012 Qamar received $18 million from Medicare in 2012, which is four times more than the next highest paid cardiologist.

The New York Times reports that Qamar and his practice have been accused of performing numerous unnecessary procedures patients involving vessels outside the heart. Patients were also reportedly given unplanned diagnostic imaging testing even when they were undergoing treatment for unrelated matters.

Extendicare Health Services Inc., a nursing and rehabilitation facilitation chain, has agreed to pay $38 million to settle Medicaid and Medicare fraud claims that were originally brought in a whistleblower lawsuit. The chain is accused of billing for substandard care and submitting claim for therapy services that were medically unnecessary. Extendicare is one of the largest nursing home chains in the United States.

The primary whistleblower in this Medicaid fraud case is Tracy Lovvorn, a physical therapist who was retained as a rehabilitation director by an Extendicare subsidiary. Lovvorn is entitled to $1.8 million of the government’s settlement. Another relator, Donald Gallic, also filed a qui tam case against the nursing and rehab chain. He is entitled to a nearly $260,000 award.

The allegations against Extendicare include the failure to adequately staff its 146 facilities in 11 states, inadequate catheter care, failure to follow protocols for pressure ulcers and falls, and improper administration of medications. According to officials, the nursing and rehab care was so unsatisfactory at certain Extendicare facilities that staff failed to prevent head injuries, fall accidents, and bedsores. Certain patients developed infections or became dehydrated or malnourished. Some individuals needed hospital care because of the negligent nursing care provided to them. These residents and their families could be entitled to nursing home neglect compensation.

Amedisys, a home heath company that operates in over three dozen states, has agreed to pay $150 million to resolve Medicare Fraud claims brought by a former employee. According to a whistleblower lawsuit, between 2008 and 2010, a number of the company’s offices improperly billed Medicare.

April Brown, a nurse, said Amedisys violated the False Claims Act when it turned in false home healthcare billings to Medicare. She says that the company asked her to bill for services that were not necessary or were never actually provided. She also worked with patients who weren’t actually homebound. Brown and other nurses were purportedly pressured into providing care that benefited the home health care’s financial needs instead of the health needs of patients.

Brown contends that when she questioned what was going on, she was let go from her job. She then became the first person to file a qui tam case against Amedisys. Several other individuals followed and their respective cases were consolidated in federal court.

Halifax Health has reached a tentative deal to pay $85 million dollars as part of a federal whistleblower case accusing the hospital of Medicare fraud and paying kickbacks to neurosurgeons and doctors. The lawsuit is .S. et al. v. Halifax Hospital Medical Center et al and was filed by hospital employee Elin Baklid-Kunz.

The deal was reached just as the case was about to go to trial. However, a second part of Baklid-Kunz’s case, accusing Halifax of increasing revenues by admitting patients who could have been discharged to stay overnight, is scheduled for trial this summer. Possible liability for that could reach $400 million.

Baklid-Kunz continues to work at Halifax Health. Previously she worked for years for them in financial and regulatory compliance. Now she is director of physician services. Baklid-Kunz filed her Qui Tam case under the False Claims Act and she is entitled to a percentage of what is recovered. According to the News-Journal Online, Baklid-Kunz and her lawyers will get $20.8 million.

Ensign Group Inc., which runs nursing homes in a number of US states, has consented to pay $48 million to settle Medicare billing fraud allegations that it billed the government for medical procedures that patients didn’t need. The case stems from whistleblower cases brought by Carol Sanchez and Gloria Patterson, two ex-employee therapists who claimed that the nursing home operator conducted rehabilitation therapy that was not always necessary at six of its facilities. The government believes that Medicare fraud took place at Ensign Group facilities from 1999 to 2011. According to the US Department of Justice, Ensign Group provided the therapy to up its Medicare reimbursement.

One whistleblower lawsuit accused Ensign of promoting fraudulent billing by establishing Medicare billing goals that were not reasonable and giving rewards, such as all-expense paid vacations, to employees who met these objectives. The Medicare fraud attorney of one of the plaintiffs said that the only way to meet these goals was to cheat Medicare. As a result, Ensign staff purportedly billed more than the care that was actually provided/needed by patients to meet the incentive goals.

Ensign Group says that even though it is settling, the company never took part in any illegal behavior. It says that it is choosing to resolve the claims to avoid litigation.

Three doctors are suing Vanderbilt University Medical Center for Medicare fraud. They submitted their whistleblower lawsuit under the False Claims Act’s qui tam provision.

The plaintiffs, all ex-VUMC anesthesiologists, are accusing the medical center of taking part in a scam involving the use of its medical practices to maximize income through the submission of false claims to state and federal health insurance programs, even though it knew that the doctor services they were billing for did not satisfy Medicare’s terms for these services. The Mediare fraud lawsuit contends that these false billing practices went on for over 10 years.

Federal law only lets hospitals bill Medicare and state insurance programs for “teaching physician services” if the teaching doctor was there during key portions of the procedure. During surgeries, the teaching physicians has to be there for the “critical” moments, as well as easily and immediately available in the event that his/her services are required at any other time during the procedures.

According to a whistleblower lawsuit, Quest Diagnostics and Laboratory Corporation of America Holdings committed Medicaid fraud by billing the program in Virginia a higher rate than other customers. Quest is the largest operator of medical labs in the United States.

Hunter Laboratories LLC and its CEO Chris Riedel submitted the whistleblower complaint. They contend that the two companies submitted false claims for payment of laboratory tests that were Medicaid covered by falsely presenting that the fees charged were not any higher than the maximum payable under regulations in Virginia, where the program was located. The plaintiffs claim that Quest billed Medicaid up to $10.42 for an automated hemogram, even though others were billed as little as $1.42 for the common blood test.

The Medicare fraud lawsuit is accusing LabCorp. of billing Medicaid fees way over what Premier Inc. purchasing collective members were charged. Riedel and Hunter have also filed fraud claims against the two companies in Georgia.

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