Lawsuits Claim Skilled Nursing Chain Submitted False Claims to Medicare for Medically Unnecessary Rehabilitation Therapy
Three whistleblowers have received the backing of the federal government in their False Claims Act lawsuits against SavaSeniorCare LLC. The company operates approximately 200 skilled nursing facilities. According to the whistleblowers, the company submitted false claims to Medicare for rehabilitation therapy services that were not medically necessary. They claim that the company set targets for Medicare reimbursement rates without regard to patient needs, and then pressured staff to meet those targets. As a result of this pressure, the whistleblowers claim, patients continued to remain in the facilities even after they were medically ready to be discharged. The whistleblowers brought their claims under the qui tam provisions of the False Claims Act. That law allows individual citizens to file lawsuits on behalf of the government and to share in any recovery. The lawsuits were filed “under seal” (in secret) and the whistleblowers' evidence was provided to the government. After conducting an investigation, the government decided to intervene in the lawsuits. The whistleblowers will be entitled to a reward of between 15% and 25% of the amount to government recovers as a result of their qui tam lawsuits. If you have evidence that a healthcare provider is submitting false claims to Medicare or Medicaid, then you should consult with an experienced whistleblower lawyer immediately to protect your rights. You may be entitled to a substantial financial reward and legal protections as a whistleblower. To schedule a free and confidential consultation, call John Howley, Esq. at (212) 601-2728. If your employer is submitting false claims to Medicare or Medicaid, you have a stark choice. You can become a whistleblower and earn a substantial reward by helping the government stop the fraud, or you can go along with your employer and face serious prison time when your employer finally gets caught.
An EMT and ambulance driver in Philadelphia learned this the hard way when they were convicted on charges of conspiracy to commit health care fraud and making false statements to the government. They now face up to 15 years in prison and a $500,000 fine each when they are sentenced. According to the government, Brotherly Love Ambulance, Inc. submitted false claims to Medicare and Medicaid for ambulance transports that were not medically necessary and were not provided in ambulances with the required lifesaving equipment. In addition to prosecuting the owner of the ambulance company, the government also prosecuted the Emergency Medical Technician (EMT) and ambulance driver who prepared the “run sheets” for the ambulance transports. EMT Fritzroy Brown and ambulance driver Thael Kuran were convicted of signing false run sheets or trip reports that the ambulance company used to support its claims to Medicare and Medicaid. According to the government, the run sheets misstated the patients’ medical conditions by failing to disclose that the patients were able to walk. Under Medicare and Medicaid regulations, patients who are not bed confined and are able to walk are not eligible for ambulance transport reimbursement. They must be transported in less expensive medical vans. The run sheets also indicated that the patients were always transported in ambulances when, in fact, they were sometimes transported in vans that lacked the lifesaving equipment required for ambulance transports. The ambulance company used these false run reports to bill Medicare and Medicaid for more expensive ambulance transports. The EMT and ambulance driver in this case could have made a much better choice. If they had consulted with a whistleblower lawyer, they could have earned a large financial reward and most likely avoided any criminal charges. Under the False Claims Act, an individual with evidence of false claims to Medicare or Medicaid can file a lawsuit “under seal” (that is, in secret) and present their evidence to the government. If the government recovers money as a result of the lawsuit, the whistleblower is entitled to a reward of between 15% and 30% of the amount recovered. If you have evidence that your employer is submitting false claims to Medicare or Medicaid, do not go to prison for them. Contact an experienced whistleblower lawyer and find out if you are eligible for a substantial financial reward and legal protections as a whistleblower. To schedule a free and confidential consultation, call John Howley, Esq. at (212) 601-2728. The U.S. Department of Health and Human Services, Office of Inspector General has identified a number of billing problems with sleep clinics that provide polysomnography services, a type of sleep study used to diagnose obstructive sleep apnea and other sleep disorders.
Some of the billing problems include: billing under inappropriate diagnosis codes; inadequate documentation of services rendered; sleep study services provided by medical staff who lack the proper certifications; and questionable billing patterns. The amount of money involved is significant. Medicare paid more than $680 million for polysomnography services between 2011 and 2012. In January 2013, one sleep clinic paid $15.3 million to settle allegations that it submitted false claims for sleep studies to Medicare and other government programs. More recently, an OIG audit found that another sleep clinic had submitted more than $1 million in false claims to Medicare for sleep studies. In the most recent case, OIG found that only 21% of the Medicare claims it reviewed were valid. Fully 79% of the Medicare claims it reviewed were for sleep studies that did not meet Medicare requirements. OIG found that 71% of the claims reviewed did not have adequate supporting documentation; 4% of the claims reviewed involved an attending sleep technician or reviewing physician who did not have the proper certification; and 1% of the claims reviewed involved billing for services that were never actually provided. Medicare claims for reimbursement of sleep testing must be supported by documentation of a face-to-face clinical evaluation by a treating physician, the patient’s sleep history and symptoms, and a physical examination that documents body mass index, neck circumference, and a focused cardiopulmonary and upper airway evaluation. The failure to maintain adequate documentation may render Medicare claims false for purposes of the False Claims Act. Depending on the state where the testing occurred, the sleep technician must have appropriate training certifications, such as Registered Polysomnography Technologist or Registered Electroencephalographic Technologist. The raw data from the sleep test must be reviewed and interpreted by a physician with an appropriate sleep certification, such as Diplomate of the American Board of Sleep Medicine. Claims for reimbursement to Medicare are considered false claims if the technician does not have the proper certification or if a physician with the proper certification does not review and interpret the raw data. If you have evidence that a sleep clinic is submitting false claims to Medicare or another government program, then you should consult with an experienced whistleblower lawyer to protect your rights. You may be entitled to a substantial reward and legal protections as a whistleblower. To schedule a free and confidential consultation, call John Howley, Esq. at (212) 601-2728. Whistleblowers Alleged Millennium Laboratories Submitted False Claims to Medicare and Medicaid for Unnecessary Drug and Genetic Testing
A group of whistleblowers will share more than $31 million in rewards as part of a settlement of claims that Millennium Laboratories billed Medicare, Medicaid and other government healthcare programs for unnecessary urine and genetic testing. The whistleblowers also alleged that the laboratory company gave free supplies to physicians in return for patient referrals. The whistleblowers alleged that the lab company promoted so-called “custom profiles,” which effectively created standing orders from physicians for large numbers of lab tests without an individualized assessment of each patient’s needs. These standing orders allegedly resulted in Medicare and Medicaid paying for urine and genetic tests that were not medically necessary for the diagnosis and treatment of an individual patient’s illness or injury. The whistleblowers also alleged that the lab company provided physicians with free urine drug test cups, but only if the physicians agreed to return the urine specimens to the lab company for lab testing. The Stark Law and the Anti-Kickback Statute generally prohibit laboratories from giving physicians anything of value in exchange for patient referrals. The lab company agreed to settle these allegations by paying $256 million. Of that amount, the whistleblowers will receive more than $31 million in rewards. The lawsuits were filed by current and former employees, competitors, and private insurance companies under the qui tam or whistleblower provisions of the False Claims Act. A qui tam lawsuit is filed by a private individual or entity on behalf of the government to recover money paid by the government for false claims. The qui tam suit is initially filed “under seal” (i.e., in secret), and the whistleblower’s evidence is provided to the government. After conducting an investigation, the government decides whether to pursue the case. If the government recovers money as a result of the qui tam lawsuit, the whistleblower is entitled to a reward of between 15% and 30% of the amount the government actually recovers. If you have evidence that a lab company or healthcare provider has submitted false claims to Medicare or Medicaid, then you should consult with an experienced healthcare fraud whistleblower lawyer immediately to protect your rights. You may be entitled to a substantial reward and legal protections as a whistleblower. To schedule a free and confidential consultation, call John Howley, Esq. at (212) 601-2728. A former Vice President of Clinical Operations for a hospice and palliative care facility has won a whistleblower reward after her former employer agreed to pay $2.2. million to resolve allegations that it filed false claims for reimbursement with Medicare.
In 2014, Cheryl Sifford filed a lawsuit “under seal” (i.e., in secret) against her former employer under the qui tam or whistleblower provisions of the False Claims Act. Under that statute, a private citizen may bring a lawsuit on behalf of the government to recover for false claims and share in any recovery. Once a qui tam lawsuit is filed under seal, the government reviews the whistleblower’s evidence, conducts an investigation, and decides whether or not to pursue the claims. If the government recovers money as a result of the lawsuit, the whistleblower is entitled to a reward of between 15% and 30% of the amount recovered. In this case, the whistleblower alleged that her former employer, Serenity Hospice and Palliative Care, knowingly submitted false claims for payment to Medicare for hospice patients. The Medicare hospice benefit is available for patients who elect palliative care for a terminal illness and who have a life expectancy of six months or less if their illness runs its normal course. Palliative care is medical care focused on providing patients with relief from pain, symptoms, or stress. Once a Medicare patient is admitted to a hospice, he or she is no longer entitled to Medicare coverage for care designed to cure his or her illness. The hospice in this case agreed to pay $2.2 million to resolve claims that it improperly certified patients as eligible for palliative care, pressured employees to admit patients for palliative care regardless of the patient’s prognosis, failed to maintain the proper paperwork to support claims for hospice care, and provided limousine rides, dinners and concert tickets to individuals in return for patient referrals. The settlement resolved these claims without an admission of liability by Serenity or a concession by the United States that its claims are not well founded. The amount of the whistleblower’s reward has not yet been determined, but it should be between 15% and 25% of the amount the government actually recovers, or between $330,000 and $550,000. If you have evidence that a hospice or palliative care center is submitting false claims to Medicare, then you should consult with an experienced healthcare fraud whistleblower lawyer immediately to protect your rights. You may be entitled to a substantial reward and legal protections as a whistleblower. To schedule a free and confidential consultation, call John Howley, Esq. at (212) 601-2728. An orthopedic surgeon has been awarded an $18.1 million whistleblower reward for helping the government uncover and stop a hospital’s program of paying above-market compensation to physicians in return for patient referrals.
Dr. Michael K. Drakeford, an orthopedic surgeon, was offered a contract with a hospital that would have paid him above-market compensation in return for referring his patients to the hospital. Recognizing that the contract might violate the Stark Law, the physician sought legal advice. The Stark Law prohibits hospitals from billing Medicare or Medicaid for services that have been referred by physicians with whom the hospital has an improper financial relationship. There are many exemptions or “safe harbors” in the Stark Law to allow for legitimate compensation relationships. But the hospital may not pay more than the fair market value for the physician’s actual services, and it may not condition the payments on the volume or value of the physician’s referrals of patients to the hospital. Instead of entering into what he believed to be an illegal contract, Dr. Drakeford started a whistleblower lawsuit under the False Claims Act. That statute allows an individual to commence a lawsuit on behalf of the government to recover for false claims to Medicare, Medicaid, and other government programs. The lawsuit was filed “under seal” (i.e., in secret), and the physician’s evidence was provided to the government. After conducting an investigation, the government decided to take over the lawsuit. At trial, the jury found that the hospital had submitted more than 21,000 false claims to Medicare. Under the False Claims Act, a whistleblower is entitled to a reward of between 15% and 30% of the amount actually recovered by the government. In this case, the whistleblower will receive an $18.1 million reward. If you have evidence that a hospital is paying above-market compensation to doctors in return for patient referrals, then you should consult with an experienced whistleblower lawyer immediately to protect your rights. You may be eligible for a substantial reward and legal protections as a whistleblower. To schedule a free and confidential consultation, call John Howley, Esq. at (212) 601-2728. A hospital in Albany, New York agreed to pay $3,373,898.28 to resolve improper Medicare claims for hyperbaric oxygen therapy treatments (HBOT).
Our Lady of Lourdes Memorial Hospital determined after an internal review that it had improperly billed Medicare for hyperbaric oxygen therapy services rendered by a third party in a facility that failed to satisfy the requirements for “provider-based status.” As a result, the hospital received payments from Medicare that it was not entitled to receive. When a hospital-owned entity qualifies for “provider-based status,” Medicare will reimburse for both a facility fee and a professional fee for services. To qualify for this status, however, a hospital-owned entity that does not physically reside within the hospital must comply with very specific requirements promulgated by the Centers for Medicare and Medicaid Services (CMS). The provider-based entity must operate under the same license as the hospital, and it must be financially and clinically integrated with the hospital. Financial integration includes the sharing of income and expenses, as well as the reporting of provider-based facility costs in the hospital’s financial statements. Clinical integration includes common medical staff privileges, integration of medical records, and central control of quality assurance. These are just a few of the many requirements. Billing Medicare for facility fees and professional fees without complying with all of the provider-based status requirements can result in significant liability under the federal False Claims Act, including restitution of three times the amount paid by Medicare and penalties of up to $11,000 per claim. By disclosing the improper billing and Medicare payments, the hospital in this case avoided potential treble damages and penalties that the government could have sought under the False Claims Act. The government also agreed that the hospital would not have to enter into a corporate integrity agreement that could have required extensive monitoring and reporting in the future. Last year, whistleblowers helped the government recover more than $2.4 billion by coming forward with evidence of Medicare and Medicaid fraud.
One of the most common types of fraud is called “upcoding.” This involves billing for a more expensive service than was actually provided. Other types of Medicare and Medicaid fraud include billing for services that were not medically necessary, billing for services separately when they should have been billed as a single, less-expensive “bundle,” billing for services provided by an uncertified provider, and recruiting Medicaid patients by paying kickbacks for referrals. Click here for information on the different types of Medicare and Medicaid fraud. These frauds result in billions of dollars in losses to the Medicare and Medicaid programs every year. The $2.4 billion recovered with the help of whistleblowers last year is only the tip of the iceberg. In almost every case, the fraud never would have been discovered without the whistleblower’s help. While the patient may have some idea of the services they received, he or she has no idea what the hospital or clinic wrote on the claim submitted to Medicare or Medicaid, whether they used the correct billing code, or whether the person in the white lab coat was a nurse, a physician’s assistant, a medical technician, or an uncertified employee. Healthcare fraud will only be stopped if current and former employees come forward with evidence. That is why the government pays substantial rewards to whistleblowers –- between 15% and 30% of the amount recovered with the whistleblower’s help. It is not unusual for a whistleblower to receive hundreds of thousands of dollars as their reward. In some cases, the rewards run into the millions of dollars. If you have evidence of false claims submitted to Medicare or Medicaid, then you should consult with an experienced whistleblower lawyer immediately to protect your rights. You may be entitled to a substantial reward and legal protections as a whistleblower. To arrange a free and confidential consultation, call John Howley, Esq. at (212) 601-2728. A former Abbott Laboratories employee will receive a $1 million whistleblower reward for reporting kickbacks between the pharmaceutical giant and the second largest nursing home consulting pharmacy in the country.
Meredith McCoyd and another former Abbott Laboratories employee brought lawsuits under the qui tam or whistleblower provisions of the False Claims Act. Under that law, an individual citizen who has evidence of false claims submitted to government programs may start a lawsuit on behalf of the government. The lawsuit is filed “under seal” (in secret) and the evidence is disclosed only to the government. The government then investigates the claims and decides whether to pursue the suit. If the government recovers money as a result of the lawsuit, the whistleblower is entitled to a reward of between 15% and 30% of the amount actually recovered. Ms. McCoyd filed a qui tam lawsuit alleging that Abbott Laboratories paid kickbacks to pharmacies in exchange for promoting the company’s prescription drug Depakote for nursing home patients. She alleged that the kickbacks were disguised as rebates, educational grants and other financial support. Under the Anti-Kickback Law, it is illegal for a pharmaceutical company or healthcare provider to offer or pay anything of value in return for referrals of Medicare or Medicaid patients. If kickbacks are paid, then every resulting claim for reimbursement is deemed a “false claim.” Both the entity that pays the kickbacks and the entity that receives the kickbacks may be liable for treble damages and penalties. In this case, the consulting pharmacy agreed to pay $6.5 million to the federal government and $2.5 million to state governments to resolve claims that it accepted kickbacks from Abbott Laboratories. The whistleblower who started the qui tam lawsuit will receive a reward of $1 million from the federal government. She may also receive whistleblower rewards from the state governments under their false claims acts. If you have evidence that a pharmaceutical company or healthcare provider is paying or receiving anything of value in return for patient referrals, then you should consult with an experienced whistleblower lawyer immediately to protect your rights. You may be eligible for a substantial reward and legal protections as a whistleblower. To arrange a free and confidential consultation, call John Howley, Esq. at (212) 601-2728. Whistleblowers Reported Kickbacks for Patient Referrals and Claims for Inpatient Detoxification Services Provided Without the Necessary License
Three New York hospitals and a Missouri-based management company agreed to pay more than $8 million to resolve claims that they submitted false claims to Medicare and Medicaid for inpatient detoxification treatment provided to patients at the hospitals. The defendants are Benedictine Hospital, Columbia Memorial Hospital, St. Joseph’s Medical Center, and SpecialCare Hospital Management Corporation. The hospitals operated inpatient drug and alcohol detoxification programs under the name "New Vision" without the necessary licenses from the New York State Office of Alcoholism and Substance Abuse Services. When claims are submitted to Medicare and Medicaid for treatment provided without a proper license, the claims are considered “false claims” even if the treatment was medically necessary and properly performed. The government also alleged that two of the hospitals, Columbia Memorial and St. Joseph’s, paid SpecialCare for patient referrals. Paying or exchanging anything of value in return for referrals of Medicare or Medicaid patients violates the Anti-Kickback law. Any claims submitted to Medicare or Medicaid for services provided after a kickback has been paid are considered “false claims” for purposes of the False Claims Act, even if the services were medically necessary and properly provided. The government began its investigation after whistleblowers commenced qui tam or whistleblower lawsuits under the False Claims Act. Under that statute, individual citizens who have evidence of fraud may start a lawsuit on behalf of the government and earn a reward of between 15% and 30% of the amount the government recovers. While the amount of the whistleblowers’ rewards have not yet been determined, the rewards should be in the range of $1.2 million and $2 million in this case based on the size of the settlement. If you have evidence that a healthcare provider has paid kickbacks for patient referrals or submitted false claims to Medicare or Medicaid, then you should consult with an experienced whistleblower lawyer to protect your rights. You may be entitled to a substantial reward and legal protections as a whistleblower. Call John Howley, Esq. at (212) 601-2728 to arrange a free and confidential consultation. |