Articles Tagged with attorney for health care whistleblowers

alex-boyd-260321-copy-300x200Sentencing for four California residents who pleaded guilty to conspiracy to commit health fraud was recently handed down. Geoffrey Ricketts, 49, Marla Ricketts, 38, Samuel Kim, 41, and Sunyup Kim, 40, all pleaded guilty in late 2016 and early 2017 after being indicted in June 2015.

Glucose Meter Fraud Scheme

These individuals created a fraudulent scheme regarding the sale of “talking glucose meters,” which were not medically needed or requested by consumers. They did so through the operation of Care Concepts, LLC and Choice Home Medical Equipment and Supplies (“Care Concepts”). The main corporate business was based out of Louisiana, while Care Concepts had its principal place of business in Chatsworth, California.

samuel-zeller-360588-copy-200x300In early October, a California federal judge dismissed without prejudice a False Claims Act (FCA) lawsuit against UnitedHealth Group Inc. (UHG). The suit, U.S. ex rel. Swoben v. Secure Horizons, et al., alleged UHG ignored questionable diagnoses that led to higher reimbursements through the Medicare Advantage program. This is significant news for the U.S. Department of Justice (DOJ). The UHG case was the first FCA suit related to the Medicare Advantage program that the DOJ joined. This was essentially a test case to determine the strength of the DOJ’s position and the ability to bring similar cases in the future. Unfortunately, this dismissal signals there were numerous weaknesses in the DOJ’s FCA case.

The Basis for the FCA Claim

This qui tam suit was brought by a whistleblower who alleged UHG knowingly ignored questionable patient charts reviewed by another company, Healthcare Partners LLC. These charts, whether or not they had appropriate evidence, contained diagnoses that would increase the insurer’s risk adjusted payments under the Medicare Advantage program. Under Medicare Advantage, healthcare providers receive higher reimbursements for caring for sicker patients.

vladimir-kudinov-71455-copy-300x241There is a misconception that the U.S. Department of Justice (DOJ) is mainly interested in health care fraud and violations of the False Claim Act (FCA) from large corporations like major insurers or pharmaceutical manufacturers. However, this is not true. The DOJ is on a mission to uncover health care fraud at all levels of care, including with individual physicians, local hospitals, regional insurers, and multi-national businesses. This is evidence by two recent DOJ announcements regarding settlements with a family practice chain in South Carolina and a hospital operator in New York.

South Carolina Family Medicine Centers

The Family Medicine Centers of South Carolina LLC (FMC) agreed to pay the U.S. $1.56 million to resolve allegations of FCA violations. FMC is a physician-owned chain of five, previously six, medical practices located in Columbia, South Carolina, and the surrounding area. FMC’s principal owner and chief executive officer Dr. Stephen F. Serbin and FMC’s former laboratory director Victoria Serbin will pay $443,000 to personally resolve allegations of FCA violations.

daan-stevens-282446-copy-300x191CHRISTUS St. Vincent Regional Medical Center, located in Santa Fe, New Mexico, and CHRISTUS Health, located in Irving, Texas, have agreed with the U.S. Department of Justice to resolve allegations of violating the federal False Claims Act (FCA) with a settlement of $12.24 million plus interest.

A Qui Tam Suit

The allegations against the CHRISTUS health care companies were made by a former indigent healthcare administrator under the qui tam provision of the FCA. This whistleblower provided information that the two health care companies were making illegal donations to county governments. Between 2001 and 2009, the CHRISTUS companies allegedly made donations in bad faith to various counties, which in turn caused New Mexico to present false claims to the federal government through the Medicaid program.

david-everett-strickler-196946-copy-300x195On July 13, Attorney General Jeff Sessions and Department of Health and Human Services (HHS) Secretary Tom Price, M.D., announced the Department of Justice’s largest ever health care fraud enforcement action. The work of the Medicare Fraud Strike Force, established in 2007, led to 412 defendants being charged with health care fraud offenses based on information they all participated in fraudulent schemes to obtain about $1.3 billion in false billings to Medicare, Medicaid, and TRICARE. Additionally, HHS has begun the suspension process against 295 health care providers’ licenses.

Hundreds of Individuals Charged With Health Care Fraud

Of the 412 defendants, 115 are physicians, nurses, and other licensed medical professionals. Many of these defendants were charged with federal crimes for prescribing medically unnecessary drugs and compound medications, many of which were not actually distributed to the patients or purchased. Providers could then bill for these unnecessary or unpurchased medications and receive a greater amount of reimbursements from state and federal health services.

jimi-filipovski-189724-copy-300x176There are currently two False Claims Act (FCA) qui tam cases against United Health Group (UHG) pending in the Central District of California. The cases are: U.S. ex rel. Benjamin Poehling v. UnitedHealth Group, Inc. and U.S. ex rel. Swoben v. Secure Horizons, et al. The cases were brought by James Swoben, who was previously an employee of Senior Care Action Network Health Plan and a consultant within the risk adjustment industry, and Benjamin Poehling, who was the former finance director of a UHG group that managed the insurer’s Medicare Advantage Plans.

The Qui Tam Cases Against UHG

On May 2, the U.S. intervened in the Swoben False Claims Act suit against UHG based on the allegations the insurer overcharged Medicare Advantage and prescription drug programs. In the DOJ’s complaint, it alleges the insurer knowingly ignored patients’ medical conditions to increase payments it received from Medicare and funded chart reviews to increase the risk adjustment payments it reviewed. However, any information the reviews uncovered regarding misdiagnoses were disregarded to avoid repaying Medicare.

benjamin-child-17946-copy-300x200A radiation therapy center based in Lancaster agreed to pay $3 million to the federal government to resolve a claim that it committed healthcare fraud for close to 10 years. A qui tam suit based on the federal False Claims Act, filed by former employee Jared Shindler, alleged that Valley Tumor Medical Group submitted fraudulent bills to the federal Medicare, Medi-Cal, and TRICARE programs between Jan. 3, 2006 through Nov. 13, 2015. According to the whistleblower suit, radiation oncology treatments were provided to patients at Valley Tumor’s Ridgecrest location when no physicians were on site, which is required by federal law.

The Case Was Made Public April 20

While the lawsuit was filed in 2015, it was only recently unsealed. That is because qui tam cases are filed under seal so that the government has time to investigate the claim and determine whether to join the suit as a party or decline to join. During this time, the lawsuit must remain a secret from the public, including the defendant. If the relator or government leaks information about the existence of the suit, there can repercussions such as fines or the dismissal of the suit.

freestocks-org-126848-1-copy-300x200The University of California recently announced that it uncovered evidence of a fraudulent health care scheme targeting students. Local health care providers would recruit and encourage students to enroll in fake clinical trials or apply for fake jobs. This allowed them to gain the student’s personal and health plan information. These providers would then write fake prescriptions in the student’s names to ultimately obtain close to $12 million from UC. The university found at least nine individual health care providers were involved.

UC Filed Complaint in Los Angeles County

UC filed a complaint against the allegedly fraudulent health care providers on April 20 in the Los Angeles County Superior Court. Listed as defendants are California Clinical Trials, LLC, Studios Pharmacy, Excel Care Pharmacy, Pharma Pro Solutions, and 17 individuals, including physicians, surgeons, pharmacists, nurse practitioners, physician assistants, and other medical professionals.

bob-brents-182206-300x240The federal government has once against settled a qui tam claim based on the False Claims Act (FCA) with a medical provider. In April, the government announced it came to an agreement with dermatologist and surgeon Dr. Norman A. Brooks, M.D., for $2,681.400 based on false billings to Medicare. Dr. Brooks owns a medical facility in Encino, California. The federal government continues to aggressively enforce the FCA and health care providers are a main target. Fraudulent claims to Medicare and Medicaid are unfortunately common and can unlawfully keep millions of dollars from the federal government.

Qui Tam Claim Against California Dermatologist

Dr. Brooks’ former employee Janet Burke brought the qui tam lawsuit under the FCA against the physician. Burke alleged that Dr. Brooks would falsely diagnose patients with skin cancer in order to bill Medicare for services and Mohs surgeries he unnecessarily performed. Mohs micrographic surgery is a procedure to remove certain types of skin cancers in certain areas of the body. It is known as the best way to remove Basil Cell Carcinoma and Squamous Cell Carcinoma. It leaves behind the greatest amount of healthy tissue. Dr. Brooks would invoice for this type of surgery because it was more costly and returned a higher reimbursement than other procedures for removing skin cancer or lesions.

 jimi-filipovski-189724-copy-300x176In the qui tam case of BlueWave Healthcare v. U.S., the government was allowed to execute writs of attachment against both real and personal property and writs of garnishment against bank accounts of the defendants under the Federal Debt Collection Procedures Act (FDCPA). The defendant’s attempted to appeal the denial of their motions to quash these writs, but this appeal was dismissed for lack of jurisdiction.

About the Case

The qui tam case was filed by Scarlett Lutz and Kayla Webster against BlueWave HealthCare Consultants, Robert Bradford Johnson, and Floyd Calhoun Dent in 2014. Lutz and Webster, the relators, alleged that the defendants had violated the Anti-Kickback Statute and the False Claims Act. They stated that the defendants arranged for illegal kickback payments to doctors, which were labeled processing and handling fees. The federal government intervened in the case in April of 2015.