Articles Tagged with health care fraud attorney

daniel-frank-201417-copy-300x200CareCore National, LLC and the U.S. Department of Justice entered into a settlement agreement, according to a May announcement. CareCore will pay $54 million to resolve a False Claims Act suit based on allegations it fraudulently billed government insurance programs. The business provides pre-authorization/pre-certification services to managed care plans. It determines whether diagnostic testing is medically reasonable and necessary for patients and should be paid for by health insurers. However, the allegations brought by a previous employee stated that CareCore did not follow its protocol and directed nurses to move forward with medical services that were not reviewed or medically necessary. This caused hundreds of thousands of inappropriate and unnecessary diagnostic tests to be approved and billed to Medicare and Medicaid.

Why the Whistleblower Came Forward

CareCore’s previous employee, John Miller, a licensed practical nurse, filed the qui tam suit against the business on behalf of the government. Miller acted as a clinical reviewer for the company and was required to assess whether a medical procedure met certain criteria for being approved. If the service was necessary and appropriate, it would be submitted to the insurance company for payment. Due to the high demand for its services, CareCore could not keep up. In response to the demand, it created the program known as Process As Directed (PAD). Through this program, clinical reviewers like Miller automatically approved prior authorization requests without a physician performing an independent review. This enabled CareCore to return more pre-authorization requests in a shorter period of time. PAD ultimately led to more than 200,000 deceptive authorizations between 2005 and 2013. Medicare and Medicaid paid for many of these unnecessary and fraudulently approved tests.

jimi-filipovski-189724-copy-300x176The U.S. Department of Justice and CVS Health Corp.’s Omnicare Inc. have settled a suit based on the federal False Claims Act for $8 million. Omnicare is the country’s largest nursing home pharmacy. It was formed in 1981 and acquired by CVS Health in 2015. Prior to this takeover, the U.S. Federal Trade Commission blocked Omnicare’s hostile takeover of competitor PharMerica. Had Omnicare purchased the business, it would have had 57% of the market share for long-term-care pharmacies. The most recent FCA settlement with the federal government is one in a long line of settlements based on fraudulent and unlawful claims to federal programs.

Omnicare’s Most Recent FCA Settlement

In a qui tam brought by Elizabeth Corsi and Christopher Ezzie in February 2014, it was alleged that Omnicare created and implemented an automated label verification system, which utilized a less specific drug code, “MEDID,” during the automated Stage II pharmacist verification process instead of a more specific National Drug Code (NDC). The result of this system was that the company submitted claims to Medicare and Medicaid for generic drugs different than those actually dispensed to patients. This created false claims to the federal government. The patient’s medication labels also had incorrect manufacturer or NDC information. Because of these issues, Omnicare could not properly track medication information or, if necessary, conduct a patient-level recall on drugs, putting patient safety at risk.

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.

healthcashAs concerned citizens and as a health care fraud law firm, our team continues to be pleased with the terrific successes whistleblowers are having using the False Claims Act, Anti-Kickback Statute and related federal and state statutes to fight fraud in the medical field.   A major settlement announced this month involving improper health care kickbacks shows just how successful these cases can be and how several different laws can work in concert to provide justice.  Yet, we know that for every victory, there are countless other companies and individuals committing health care fraud and stealing from the American people.  We cover these issues extensively to let those who witness these crimes know they are not alone.  We are here to help them follow the right path and truly do a service to their country.

DOJ Announces Largest Total Settlement Involving Illegal Kickbacks in Medical Device Field

The Department of Justice (“DOJ”) announced this month that the largest distributor of endoscopes and related equipment has agreed to pay $623.2 million to settle several lawsuits involving allegations it paid inappropriate kickbacks to doctors and hospitals.  Defendant Olympus Corporation of the Americas (“Olympus”) has admitted to the allegations in a criminal complaint filed in a New Jersey federal court based on the Anti-Kickback Statute (“AKS”) and the related suits rest on similar allegations.  This settlement involves the largest total amount paid to date by a medical device company for violations involving the AKS.  Olympus has entered into a deferred prosecution agreement that allows it to avoid criminal conviction if it complies with the reforms contained in the agreement.

By its nature, fraud is a crime of secrets.  The depth and breadth of these secrets are part of the reasons why whistleblowers are such an essential part of the fight against health care fraud.  The law recognizes this and both rewards and protects health care fraud whistleblowers for their role in helping return wrongfully diverted government health care funds to already-strained program budgets like Medicare and Medicaid.  As a whistleblowers’ law firm, The Brod Law Firm is proud to work with the men and women who speak up when others might remain silent.

Whistleblower Files Retaliation Lawsuit Against Former Employer

One whistleblower in Oregon is currently pursuing a lawsuit against his former employer claiming illegal retaliation based on his role in reporting potentially fraudulent Medicare claims.  According to The Oregonian, Dr. Robert Dannenhoffer filed a federal whistleblower claim late last week against Architrave Health LLC, a health doctor2care organization in southern Oregon.  Dr. Dannenhoffer claims that a subsidiary company, Umpqua Medical Group, set up an improper compensation structure that rewarded doctors for prescribing certain medications and procedures for Medicare patients.  He says the pay structure led to inflated Medicare payments in violation of both the False Claims Act, a general law dealing with fraudulent claims for government funds, and the Stark Act, a law specifically limiting the ability of medical providers from profiting on referrals.

It is a simple concept — health care should be dictated by the patient’s needs rather than the provider’s fiscal interest.  While most providers adhere to this core principle, far too many do not, especially in the long-term and nursing home care arenas.  Nursing home billing fraud, including rehabilitative therapy fraud, is a violation of patient trust and medical ethics as well as a serious financial wrong that diverts money away from genuine medical needs.  As a Medicare billing fraud law firm, we monitor this area of law closely and we fight back by working with honest whistleblowers who come forward to report these wrongs.

DOJ Press Release Details Alleged Frauds in Recently Settled False Claims Act Case

A Department of Justice (“DOJ”) press release issued on January 12 demonstrates the DOJ’s continuing commitment to supporting whistleblower-led Medicare billing fraud claims in 2016.  Kindred Healthcare Inc. and its subsidiaries RehabCare Group Inc. and RehabCare Group East Inc. (collectively “RehabCare”) have agreed to healthmoneypay $125 million to resolve a False Claims Act (“FCA”) lawsuit.  RehabCare is the nation’s largest provider of rehabilitative therapy, contracting with over 1,000 nursing homes nationwide to provide patient care.  Four nursing homes will also pay a total of $8.225 million in connection with the settlement.   While the settlement resolves the claims, it is not an admission of wrongdoing and all claims detailed below remain allegations.

The relationship between health care and money is the crux of some of the biggest policy debates of our time.  Still, while much is debated, there are also many principles that most Americans agree should hold true.  One such maxim – Medical decisions should be based on the best interests of patients, not providers own financial well-being.  This precept is reflected in several laws including the Anti-Kickback Statute and the Stark Act and enforcing these rules is one of the goals of our work as a whistleblowers’ law firm for health care fraud issues.

$115 Million Settlement Resolves Case Alleging Health System’s Bonuses Violated Law

Just last week, the Justice Department (“DOJ”) announced a major settlement in a health care fraud case involving allegations of improper financial relationships between health care providers and their referral sources.  The lawsuit claimed that Adventist Health Systems, a healthcare organization with facilities in 10 states, billed for the services of employed providers who were paid bonuses that, contrary to law, were based on a formula that considered the value of the referrals to the hospital system.  More specifically, the suit alleged that doctors received monetary bonuses tied to the number of tests and procedures they ordered.  Adventist agreed to pay $115 million to settle these and other fraud allegations, but did not admit to any wrongdoing.

One of the reasons we write about health care fraud is to make people aware of the true cost of these schemes.  These crimes are ultimately financial in nature, with scammers stealing billions (not a typo!) each year from government programs that are already operating on strained budgets.  As if stealing money that is supposed to go towards ensuring the health of some of our nation’s most deserving (including military families and seniors) isn’t bad enough, these crimes also have a direct impact on individual beneficiaries.  The broad, sometimes life-threatening impact of these crimes is why we urge private citizens to join the fight against health care fraud and why we are proud to serve as a law firm for health care fraud whistleblowers.

A Scheme Founded Upon False Cancer Diagnoses and Other Lies Told by a Michigan Doctor

A case from 2014 stands out as a particularly egregious example of how scammers put individuals at risk, ignoring the duties of the health care profession and risking people’s lives for profit.  The FBI’s news article paints the picture:

cash2When it comes to the world of health care fraud, there’s one truth we cannot emphasize enough – Honest individuals are the key to winning the fight against fraud.  It is a truth we see again and again in our work as a whistleblower’s law firm.  The False Claims Act (“FCA” or “the Act”) provides a financial incentive for people to elect the morally right path and report suspected cases of health care fraud and other forms of government claims fraud.  The importance of health care fraud whistleblowers in the fight for right is emphasized by the emerging story of a record-breaking case against one the nation’s largest kidney dialysis companies.

DaVita Settles False Claims Act Case for $495 Million

syringeIn 2007, according to last week’s Denver Post, Dr. Alon J. Vainer and nurse Daniel D. Barbir filed a whistleblower lawsuit against Denver’s DaVita HealthCare Partners.  The pair had been working for DaVita when they noticed the company was throwing out good medicine and dividing single use doses into multiple vials.  They only filed suit after internal questions/complaints went unanswered.  DaVita was, per the allegations, overbilling Medicare and Medicaid.  For example, the lawsuit suggests a physician would use part of a 100mg vial of Zemplar (vitamin D) or Venofer (an iron supplement), charging for the whole dosage despite the fact that the patient only needed 25mg.  In other cases, doctors were told to treat a patient who needed 8mg of medicine with a 10mg vial instead of a cheaper option of four 2mg vials.

scalesSometimes health care fraud is a well-known secret, something many in a company’s leadership know about and either passively or actively conceal.  Likewise, a number of lower-level employees may know about and be asked to help perpetuate the fraud.  Fraud takes cooperation.  How does this happen when almost everyone we meet agrees that it a blatant violation of both law and their moral codes?  Often, especially in cases involving larger organization, our Medicare fraud law firm finds health care fraud continues because the company’s structure allows it.

How Corporate Structure Can Contribute to Fraud

Earlier this year, Atlantic Information Services Inc. (“AIS”), a health care publishing and information organization, published a report on how corporate structures can contribute to health care fraud.  The Affordable Care Act mandates that Medicare/Medicaid providers have compliance programs (for an overview of this mandate, see the Medicare and Medicaid Services’ Webinar “The Affordable Care Act Provider Compliance Programs: Getting Started”).    The AIS report suggests that the compliance mission is hindered when compliance officers report to a company’s general counsel (“GC”) rather than reporting directly to the CEO or the board of directors.  According to the author, the mindset of the GC differs from that of the compliance team.  Ultimately, the article suggests legislators pass a new regulation forbidding a structure that makes the compliance department subordinate to the general counsel.