Every day, the government announces another multi-million dollar Medicare or Medicaid fraud settlement. Today there was not one announcement, but three.
First, a Johnson & Johnson subsidiary agreed to pay $18 million to settle claims that it caused physicians to submit false claims to Medicare by marketing a medical device for use as a drug-delivery device for prescription corticosteroids, when that use was not approved by the FDA. Second, a hospital in South Carolina agreed to pay $17 million to settle claims that it submitted false claims to Medicare and Medicaid, and that it provided financial incentives to doctors for patient referrals. Third, a diagnostic imaging company agreed to pay $3.5 million to settle claims that it billed Medicare and Medicaid for services that were provided without adequate supervision. Three settlements. Almost $40 million. All announced in just one, typical day in the healthcare fraud arena. Why is there so much fraud in Medicare and Medicaid? Because the government cannot find fraud without help from insiders. Medicare and Medicaid receive more than 1 million claims for reimbursement every day. There is no way for the government to know whether each of those one million claims involved services that were medically necessary, or were properly supervised, or were billed using the proper billing code and not a code for a more expensive procedure. That is why the government relies on – and rewards – whistleblowers who come forward with evidence of fraud. In the South Carolina hospital case, for example, the government began its investigation only after a physician who worked for the hospital came forward with evidence of improper billing and financial incentives. Now that doctor will receive a whistleblower reward of between 15% and 25% of the amount recovered – which will be somewhere in the range of $2.5 million and $4.25 million. 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 legal protections and a substantial reward. To schedule a free and confidential consultation with an experienced whistleblower lawyer, call John Howley, Esq. at (212) 601-2728. Do not delay. There are strict time limits and procedural requirements to qualify as a whistleblower.
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Renown Health has agreed to pay $9.5 million to settle allegations that it submitted false claims to Medicare for in-patient hospital services. According to a whistleblower complaint, the services should have been billed at much lower rates for out-patient or observation services.
The settlement resolves a qui tam or whistleblower lawsuit brought by a former employee under the False Claims Act. That law allows individuals with evidence of false claims to commence a lawsuit on behalf of the government and share in any recovery. The whistleblower in this case will receive a $1.7 million reward from the settlement. During her employment as Director of Clinical Compliance, the whistleblower noticed a number of technical billing discrepancies. One of the issues she noticed was the submission of claims to Medicare for in-patient care when it appeared that the patients had never been admitted to the hospital. After bringing her concerns to management without any success, the whistleblower brought her concerns to the government in the form of a qui tam lawsuit. Qui tam lawsuits are filed “under seal” (that is, in secret) to allow the government time to investigate before the defendant learns that it is a suspect in a Medicare fraud investigation. The government then decides whether to pursue the lawsuit on its own, or to allow the whistleblower, known as a “relator,” to pursue the lawsuit on its behalf. If the government pursues the lawsuit and wins, the relator is entitled to a reward of between 15% and 25% of the amount actually recovered. If the relator pursues the lawsuit on behalf of the government, then she is entitled to a reward of between 25% and 30% of the amount recovered plus her attorney’s fees and costs. 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 legal protections and a significant financial reward. There are, however, strict procedural requirements and time limits to qualify for a whistleblower reward. You should not delay. To schedule a free and confidential consultation with a whistleblower lawyer, call John Howley, Esq. at (212) 601-2728. Regent Management Services will pay $3.2 million to settle allegations that it received kickbacks from ambulance companies in the form of low-cost ambulance transports in exchange for referrals of Regent’s Medicare and Medicaid patients to the ambulance companies.
This is believed to be the first time a nursing home operator, as opposed to an ambulance company, has been held accountable for a “swapping” arrangement. Under such an arrangement, the ambulance company agrees to provide a nursing home or hospital with low-cost ambulance transports when the nursing home or hospital is required to pay for the transports. In return, the nursing home or hospital agrees to refer other patients to the ambulance company when Medicare or Medicaid will pay for the transports. Such “swapping” agreements violate the Anti-Kickback Statute. That law prohibits offering, paying, soliciting, or receiving anything of value in exchange for referrals of items or services covered by Medicare or Medicaid. The federal government has made clear that swapping arrangements are an area of concern throughout the ambulance industry, and that it intends to investigate and prosecute these cases aggressively. If you have evidence that an ambulance company is providing low-cost services to a hospital or nursing home in exchange for referrals of Medicare or Medicaid patients back to the ambulance company, then you should consult with an experienced whistleblower lawyer immediately. You may be 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 government has announced a $250 million settlement in whistleblower lawsuits brought against hospitals for submitting false claims to Medicare for cardiac devices implanted in patients.
The whistleblower lawsuits were brought by a cardiac nurse and healthcare reimbursement consultant. As a result of the settlement, they will share a $38 million whistleblower reward under the qui tam or whistleblower provisions of the False Claims Act. The whistleblowers claimed that the hospitals improperly billed Medicare for implantable cardioverter defibrillators or ICDs. These devices monitor the heart for abnormal rhythms and deliver a shock to restore the heart's normal rhythm. They are similar to external defibrillators, only they are implanted in the patient. Medicare pays for ICD surgery only if the patient meets certain criteria. For example, Medicare regulations provide that ICDs should not be implanted in patients until 40 days after a heart attack or 90 days after heart bypass surgery or angioplasty. The whistleblowers in this case claimed that the hospitals were violating the waiting periods, thereby obtaining reimbursement in violation of Medicare regulations and potentially creating health risks for patients. The whistleblowers filed their False Claims Act lawsuits "under seal" (in secret) and provided their evidence to the government. After conducting an investigation, the government decided to pursue the case and negotiated a settlement with the hospitals. Under the False Claims Act, the whistlebowers were therefore entitled to a percentage of the government's settlement as a reward. In this case, the whistleblower reward was $38 million. 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. You may be entitled to a substantial reward and 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. 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. Dr. Jean Moore, a physician, will receive an $825,000 whistleblower reward for reporting that his employer, a hospital and an affiliated medical clinic, submitted false claims to Medicare. The hospital and affiliated clinic have agreed to pay $5.5 million to settle the claims.
Dr. Moore alleged that the hospital and its affiliated clinic were paying bonuses to physicians in return for patient referrals. The bonuses were paid based on a formula that took into account the value of the physicians’ patient referrals. Paying anything of value in return for referrals of Medicare patients violates the anti-kickback statute. It also renders all resulting claims to Medicare “false claims” for purposes of the False Claims Act. Dr. Moore started a qui tam or whistleblower lawsuit under the False Claims Act. That law allows individual citizens to commence a lawsuit on behalf of the government for false claims submitted to Medicare, Medicaid, and other government programs. The lawsuit is filed “under seal” (in secret), and the whistleblower provides all of his evidence to the government. The government then investigates the claims. If the government recovers money as a result of the qui tam lawsuit, then the whistleblower is entitled to a reward of between 15% and 30% of the amount actually recovered. The key to a successful whistleblower lawsuit is having evidence of the false claims. It is not enough that you suspect that false claims are being filed. You must give the government evidence to support your suspicions. If you have evidence that a healthcare provider is paying kickbacks in return for patient referrals, or that it is submitting false claims to Medicare or Medicaid, then you should consult with an experienced whistleblower lawyer immediately. You may be entitled to a substantial reward and legal protections as a whistleblower. You may not file a whistleblower lawsuit on your own. The law requires that an attorney file the lawsuit for you. You will also need careful legal advice on gathering and presenting your evidence, especially if HIPAA-protected medical records are part of your evidence. Contact our law office for a free and confidential consultation. If you have a case, we will represent you on a contingency fee basis. You will not owe any legal fees unless you win. John Howley, Esq. (212) 601-2728 Children's Hospital Allegedly Filed False Cost Reports to Increase Reimbursement Rates from Medicare and Medicaid.
James A. Roark, Sr., a former employee of Children's National Medical Center, will receive a $1.9 million whistleblower reward for coming forward with evidence that his former employer submitted false cost reports to the government in order to increase its reimbursements from Medicare and Medicaid. The whistleblower reward resulted from a settlement agreement in which the hospital agreed to pay $12.9 million in restitution to the government. The whistleblower claimed that the hospital filed false cost reports that misstated its overhead, which resulted in higher reimbursement rates and overpayments from Medicare and Medicaid. According to the settlement agreement, the hospital also misreported its available bed count on an application for the Children's Hospitals Graduate Medical Education (CHGME) Payment Program. The CHGME Payment Program provides federal funds to freestanding children's hospitals to help them maintain their graduate medical education programs that train pediatric and other residents. Under the False Claims Act, an individual citizen may commence a whistleblower or qui tam lawsuit on behalf of the government to recover money for false claims submitted to Medicare, Medicaid, and other government programs. The qui tam lawsuit is filed "under seal" (in secret) and the whistleblower's evidence is given to the government, which then must conduct an investigation. If the government recovers money as a result of the lawsuit, the individual whistleblower is entitled to a reward of between 15% and 30% of the amount recovered. If you have evidence of false claims submitted to Medicare, Medicaid, or other government programs, you should consult with an experienced whistleblower lawyer immediately. You may be entitled to a substantial reward and legal protections as a whistleblower. To schedule a free and confidential consultation with an experienced whistleblower lawyer, call John Howley, Esq. at (212) 601-2728. Hospital Allegedly Paid Obstetric Clinic for Referrals of Pregnant Women
Health Management Associates and Clearview Regional Medical Center agreed to pay almost $600,000 to settle claims that the hospital paid kickbacks to an obstetric clinic in return for referrals of pregnant women for labor and delivery. The hospital's former Chief Financial Officer will receive a whistleblower reward of approximately $120,000 for helping the government pursue the claims. He may receive more money depending on the outcome of related cases against additional defendants. The hospital was accused of paying kickbacks to an obstetric clinic that provided services to undocumented pregnant women. In return for the payments, the clinic allegedly referred patients to the hospital for deliveries that were reimbursed by Medicaid. While undocumented aliens are not eligible for regular Medicaid benefits, Medicaid will reimburse hospitals for emergency services, including childbirth, for undocumented individuals. The Anti-Kickback Statute prohibits healthcare providers from paying or receiving anything of value in return for referrals of patients covered by a government healthcare program. Prohibited payments include cash, excessive compensation, low-cost office space, or anything else of value. In this case, the hospital allegedly disguised the kickbacks as payments to the clinics for services. Once a kickback has been paid, no reimbursement may be sought from Medicare, Medicaid, or any other government healthcare program for any resulting services. It does not matter if the services were medically necessary and actually provided. The kickback renders all resulting claims for reimbursement "false claims" under the False Claims Act. The former CFO pursued the case against the hospital and others under the qui tam, or whistleblower, provisions of the False Claims Act. These provisions allow private citizens to pursue claims on behalf of the government and to share in any recovery. Successful whistleblowers are entitled to rewards of between 15% and 30% of the amount the government recovers. If you have evidence that a hospital or other healthcare provider is paying kickbacks in return for patient referrals, then you should consult with an experienced whistleblower lawyer immediately. Call John Howley, Esq. at (212) 601-2728 to schedule a free and confidential consultation. |