Articles Posted in Whistleblowers and Qui Tam Lawsuits

Choosing a nursing home or other senior care facility is a difficult and emotional decision. There are many factors to consider, many of which can spark intense family debates, including location, price, and available forms of care. There are also more individualized factors like whether the prospective resident has friends at the facility, whether the facility has a religious affiliation, and the input provided by the resident’s current doctors. That last item, the advice of medical professionals, can be extremely persuasive and a good doctor will assess numerous factors before voicing an opinion. Kickbacks from nursing homes should never cloud a doctor’s professional judgment. While that may sound obvious, payments to doctor for referrals our Northern California Medicare fraud law firm knows illegal kickbacks are more common than most of us would like to think and pose both a financial threat to the Medicare program and a threat to patients’ health and well-being.

Whistleblower Alleges Kickbacks Were Key Part of Medicare Fraud by Senior Care Network

According to the Broward Bulldog, the Plaza Health Network has worked to maintain a top-notch reputation since its founding 64 years ago as a home for Jewish seniors and war veterans who could no longer live alone and/or care for themselves. Plaza is now a non-profit with corporate offices in Aventura, Florida, and runs eight care facilities in the Miami region open to seniors of all denominations. The company’s reputation may, however, change dramatically if a lawsuit alleging health care fraud is successful

Medicare fraud is a topic that is receiving increasing attention from authorities and news media alike. Our California Medicare fraud law office believes this attention is rightly placed and we support efforts to both recover wrongfully diverted funds and prevent future frauds. Two of the ways that the government accomplishes these interrelated goals is through rulemaking and through intervening in whistleblower-led health care fraud claims.

Rulemaking – New Rule Limits Enrollment by Suspect Entities

Last week, the Center for Medicare and Medicaid Services (“CMS”) announced approval of a new rule that will allow the agency to prevent future frauds by identifying persons/entities that pose particular risk to the integrity of our federal health care programs. The rule, as detailed in a CMS Fact Sheet, attempts to prevent suspect groups from enrolling in or remaining part of the system and being permitted to bill Medicare for services provided to beneficiaries. Key elements include: Denying enrollment of providers and others associated with an entity that has an outstanding Medicare debt; Denying or revoking billing privileges of groups that have a managing employee who was previously convicted of certain felonies; and Revoking the billing rights of providers and suppliers that show a pattern of improperly billing for services that fail to meet program requirements.

Sadly, it doesn’t feel unusual for someone accused of a crime to continue suspect behavior. As pending litigation against a surgeon already embroiled in health care fraud litigation became even more complex last week, it also continued to break new legal ground with allegations involving a specific form of business entity known as a physician-owned distributorship. Also known as “PODs,” these entities raise some major red flags that can point to both criminal and civil wrongdoing. While the current case is the first publicly noted health care fraud case involving PODs, our San Francisco health care fraud attorney expects that litigation will continue as long as the suspect devices are used by those who put profit over patient care.

Man Faces Health Care Fraud Charges in Both California and Michigan

A report in the journal Modern Healthcare details expanded claims filed against a doctor in Michigan who has already been stripped of his license here in California. Dr. Aria O. Sabit stands accused of committing fraud, violating naturalization laws, and performing spinal fusion surgeries in which he did not actually implant promised medical devices. When some patients in Michigan who had undergone surgery with Sabit had continued pain and sought second opinions, they were told that medical devices had not actually been placed during the initial surgeries, even though bills for the devices had been filed with government and private insurers. Sabit also, per the recently filed suit, failed to inform citizenship officials of prior felony-level health care fraud charges that would have rendered him ineligible for naturalization.

Mention the phrase “card catalog” to someone over age 30 (or maybe 35?) and they will recall searching for books in the library by leafing through small notecards listing titles, authors, and Dewey Decimal numbers. Mention the phrase to a teen and you’ll probably elicit a blank stare. The card catalog is just one example of a formerly physical record system that has been replaced by electronic records. The shift to electronic records remains a work in progress in the health care field and incentives are being offered to encourage health care organizations to make the move to electronic health records. Sadly it comes as little surprise to the experts at our health care fraud law firm in Northern California that there are those looking to take advantage of the incentives and willing to defraud the government and the health care system for their own financial gain.

CFO Falsely Told Officials Hospital Made Meaningful Use of Electronic Records

A press release carried by KTRE, an ABC affiliate in Texas, announced that a former hospital CFO pled guilty last week to making false statements that officials say were part of a larger health care fraud scheme. While acting as CFO for Shelby Regional Medical Center, Joe White oversaw the hospital’s implementation of an electronic health records system. In this role, White made statements to Medicare attesting that the hospital made meaningful use of electronic records and qualified for certain payments pursuant to Medicare’s Electronic Health Record Incentive Program. According to White’s guilty plea, he knew the hospital did not qualify as a meaningful user at the time he made these statements on November 20, 2012. As a result of White’s false attestations, the Medical Center received $785,655 from Medicare.

Most Americans know someone who has struggled to get needed care approved by his/her health insurance provider. As a result, many feel forced to choose between medical care and other essentials. A survey conducted by a national network of food banks found almost 2/3 of client households faced the unenviable choice between food and medical care costs in the past year. Both private insurance and government programs should help prevent such dilemmas, especially among the elderly, the disabled, and current/former military members. Denial of legitimate claims and the parallel issue of high medical bills are another cost of health care fraud. When individuals and groups bill for unneeded care, they waste limited resources and make honest claims look suspect. This is yet another reason our San Francisco health care fraud law firm is part of the fight against fraud.

Dignity Health Settles False Claims Act Charges

On October 30, the Justice Department announced a settlement involving allegations that a company overcharged government healthcare programs, submitting false and inflated claims and diverting money from genuine needs. Dignity Health is a San Francisco based hospital chain with 39 hospitals in three states. Dignity agreed to pay $37 million to settle False Claims Act allegations initially brought by Kathleen Hawkins, a former employee, who will receive a substantial award in recognition of her role and efforts. The company also entered into a corporate integrity agreement that requires enhanced compliance efforts over the next five years. This includes a requirement that Dignity “retain independent review organizations to review the accuracy of the company’s claims for services furnished to federal health care program beneficiaries.”

Health care whistleblowers are, in our humble opinion, pretty amazing people. They speak out against some of the nation’s biggest and most powerful companies, often taking their concern public after butting heads with company executives. Others see the same wrongs that whistleblowers spot and many are similarly upset, but whistleblowers take the critical next step — raising their concerns in a forum that can lead to change. Sadly, some people degrade whistleblowers, suggesting they are only looking for a payout. Simply stated, our California health care fraud attorney couldn’t disagree more.

From Whistleblower…

One whistleblower who demonstrates the commitment to right shared by most is Jacqueline Nash Bloink, whose story is shared by the Arizona Daily Star. Between 2010 and 2011, Bloink worked as a corporate responsibility coordinator for Carondelet Health Network, a healthcare provider in Southern Arizona. In that role, the certified medical reimbursement specialist noticed billing discrepancies in the files of Medicare, Medicaid, and the Federal Employees Health Benefit Program enrollees. Bloink filed a whistleblower suit pursuant to the False Claims Act (“the Act”) in 2011. The suit accused Carondelet of engaging in fraudulent billing practices, citing insufficient documentation to support inpatient rehab services allegedly performed at two network hospitals between April 2004 and December 2011. The U.S. Attorney’s Office helped investigate the case which settled in August for $35 million, the biggest payout to date for a federal False Claims Act case in Arizona.

Home healthcare, physical therapy and prescription drugs have been some of the more common examples of healthcare services that have been used to defraud Medicare, and, as our blogs have pointed out, many of the most notorious schemes have been emanating from Miami and South Florida, the national epicenter of Medicare fraud. However, San Francisco qui tam lawsuit lawyer Gregory J. Brod would note that healthcare fraud is spread throughout the country as well as focused on a variety of healthcare services. One example of a Medicare fraud scheme from a failing Houston hospital made headlines this week for its ambitious methods of stealing millions from the taxpayers.

According to the Houston Chronicle, the former president of the financially shaky Riverside Hospital, his son and two other persons affiliated with the facility were convicted in federal court Monday for their scheme to fleece $158 million from Medicare. Prosecutors in the case said that Riverside Hospital’s psychiatric care was a “sham,” and that the four people convicted – former hospital CEO Earnest Gibson III, his son Earnest Gibson IV, Regina Askew and Robert Crane – soaked taxpayers for services that were not rendered.

“For over six years, the Gibsons and their co-conspirators stuck taxpayers with millions in hospital bills, purportedly for intensive psychiatric treatment,” said Assistant U.S. Attorney General Leslie Caldwell. “But the treatment was a sham – some patients just watched television all day, others had dementia and couldn’t understand the therapy they supposedly received, and other patients never even went to the hospital at all.”

The convictions stemmed from an FBI probe that lasted from 2005 to 2012 and resulted in an indictment in 2012 against Gibson III and 10 others, including doctors, marketers and other persons affiliated with Riverside Hospital. Several of the 10 charged pleaded guilty, including assistant administrator Mohammed Khan, who admitted to conspiring to commit healthcare fraud.

Prosecutors stated that Gibson III paid kickbacks to recruiters and owners and operators of group care homes in return for delivering supposed patients to Riverside’s facilities. As far as the others who were convicted, Gibson IV operated a satellite patient care facility and Askew recruited patients and audited documents; both were convicted of conspiring to commit healthcare fraud and pay as well as receive kickbacks. In addition, Crane, who was a recruiter and shuttle driver, was convicted of conspiracy to commit money laundering.

Riverside Hospital has been financially beleaguered since the unsealing of the indictment in late 2012, which prompted the federal government to cut off funding to its facilities. As part of a bid to remain in business, Riverside surrendered its substance abuse treatment license in August and limited itself to detoxification services, no longer providing drug abuse and psychiatric treatment.
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