Amanda Adams was charged with Medicaid fraud involving “doctor shopping,” or using her Medicaid benefits to get multiple pain medication prescriptions by visiting different doctors. The indictment alleges four counts of fraudulently using Medicaid to obtain controlled substances. Each charge is a felony with a potential sentence of up to two years in prison. The woman’s “doctor shopping” scheme allegedly involved visiting multiple doctors to obtain prescriptions for the pain medications Lortab, Oxycodone and Tylenol III. Each time she would visit a new doctor, she failed to disclose that she had already received prescriptions for the pain medications by visiting other physicians. The physician office visits and prescriptions were paid for with Medicaid benefits. It is against the law to use Medicaid benefits to obtain prescription drugs for any reason other than prescribed, or to use benefits to go from one doctor to another to get duplicate prescriptions. Medicaid fraud is a serious offense that can result in a prison sentence. If you are under investigation or have been charged with Medicare or Medicaid fraud, then you should consult with an experienced Medicaid fraud attorney immediately. To arrange a free and confidential consultation by phone or in person, call my office today at (917) 652-6504 or click here to contact me via email. John Howley, Esq. The information you obtain at this site is not, nor is it intended to be, legal advice. You should consult an attorney for advice regarding your individual situation. I invite you to contact our law offices and welcome your calls, letters and electronic mail. Contacting us does not create an attorney-client relationship. Please do not send any confidential information to us until such time as an attorney-client relationship has been established. I practice law and offer legal services only in jurisdictions where I am properly authorized to do so. I do not seek to represent anyone in any jurisdiction where this web site does not comply with applicable laws and bar rules.
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A whistleblower lawsuit brought against Healthpoint Ltd. and DFB Pharmaceuticals was settled for $48 million. The suit was brought under the qui tam provision of the False Claims Act, which allows individuals to sue on behalf of the government and share in any recovery. Whistleblowers can be current or former employees, sales representatives, physicians, trainers, consultants, patients, customers, competitors, or anyone else with knowledge of Medicare or Medicaid fraud. Under the False Claims Act, a whistleblower who brings a qui tam suit is entitled to a reward of between 15% and 25% of the amount the government actually collects. The government and the whistleblower in this case are negotiating the amount of her reward. In this case, the settlement resolves allegations that Healthpoint caused false claims to be submitted to Medicare and Medicaid for an unapproved drug, Xenaderm, a prescription skin ointment for the treatment of nursing home patients’ bed sores. Prescription drugs that have not been approved by the Food and Drug Administration (FDA) are not eligible for reimbursement from Medicare or Medicaid. The government alleges that Healthpoint actively promoted Xenaderm as a prescription drug that, unlike non-prescription skin ointments such as Vaseline, was “Medicaid reimbursed” and therefore cost nursing homes nothing to administer to Medicaid patients. In fact, Xenaderm was not eligible for reimbursement and Healthpoint did not include Xenaderm on its quarterly list of reimbursable drugs that it submitted to the government. The government also alleges that Healthpoint did not complete any double-blind placebo-controlled clinical studies to establish the safety and effectiveness of Xenaderm. It points to an internal email written by a Healthpoint clinical researcher who admitted that the safety and efficacy data for Xenaderm was “cruelly insufficient” to meet FDA standards. The lawsuit was originally filed under seal (in secret) by the whistleblower, and the whistleblower’s evidence was provided only to the government. After reviewing the secret complaint and conducting an investigation, the government joined the lawsuit. The government and the whistleblower, have not yet agreed on the size of her award. Under the False Claims Act, she is entitled to a reward of 15% top 25% of the total amount recovered, or between $7.2 million and $12 million if the government collects the full amount of the settlement and determines that her lawsuit covered the claims that were settled. Two issues may be under negotiation. First, it is unclear whether the lawsuit filed by the whistleblower was as broad as the lawsuit the government ultimately pursued. If the whistleblower’s lawsuit had a more narrow scope, then her reward may be limited to the portion of the settlement attributable to her claims. Second, Healthpoint and DFB have agreed to pay $28 million now, plus another $20 million if there is a change in ownership of Healthpoint or DFB over the next three years. If there is no change in ownership and the settlement is limited to $28 million, then the whistleblower would be entitled only to a percentage of the amount actually paid. If you are aware of false claims being submitted to Medicare or Medicaid, then you should consult with an experienced False Claims Act attorney immediately. You may be entitled to a substantial reward and the legal protections afforded whistleblowers under state and federal laws. To arrange a free and confidential consultation, call John Howley, Esq. at (917) 652-6504 or click here to contact us via email. John Howley, Esq. The information you obtain at this site is not, nor is it intended to be, legal advice. You should consult an attorney for advice regarding your individual situation. I invite you to contact our law offices and welcome your calls, letters and electronic mail. Contacting us does not create an attorney-client relationship. Please do not send any confidential information to us until such time as an attorney-client relationship has been established. I practice law and offer legal services only in jurisdictions where I am properly authorized to do so. I do not seek to represent anyone in any jurisdiction where this web site does not comply with applicable laws and bar rules. A dentist has been sentenced to 18 months in federal prison after pleading guilty to billing Medicaid for dental services that were not provided. Robin Lockwood, D.D.S. was employed by Ocean Dental, a chain of 30 dental clinics operating in seven states. Ocean Dental states on its web site that providing dental care to low income patients covered by Medicaid is an important part of its mission. Each state is required to provide certain basic dental benefits to children covered by Medicaid, including relief of pain and infections, restoration of teeth, and maintenance of dental health. Dental benefits for adults are covered by Medicaid only if the state chooses to provide such coverage. Lockwood was charged with one count of health care fraud earlier this year. The fraud charges carried a maximum sentence of 10 years in prison and a $250,000 fine. The government alleged that she falsified treatment notes submitted by Ocean Dental for Medicaid reimbursement. She benefited from the scheme because she received a percentage of the reimbursement for her services. The government also alleged that Lockwood billed for multi-surface fillings that she did not complete, upcoded bills to receive a higher reimbursement rate than the procedures justified, and billed for services not reimbursable by Medicaid by using a different billing code. According to the government, patient x-rays and other evidence established that Lockwood was creating false claims for submission to Medicaid. If you are being audited or investigated, or if you have been charged with submitting false claims to Medicaid, then you should consult with an experienced Medicaid fraud attorney immediately. To arrange a free and confidential consultation by phone or in person, call my office today at (917) 652-6504 or click here to contact me via email. John Howley, Esq. The information you obtain at this site is not, nor is it intended to be, legal advice. You should consult an attorney for advice regarding your individual situation. I invite you to contact our law offices and welcome your calls, letters and electronic mail. Contacting us does not create an attorney-client relationship. Please do not send any confidential information to us until such time as an attorney-client relationship has been established. I practice law and offer legal services only in jurisdictions where I am properly authorized to do so. I do not seek to represent anyone in any jurisdiction where this web site does not comply with applicable laws and bar rules. The Obama Administration is a big fan of the False Claims Act and, in particular, the qui tam provisions that allow individual citizens to initiate lawsuits on behalf of the U.S. Government. Last year, the federal government recovered more than $3 billion from healthcare providers that submitted false claims to Medicare, Medicaid, and other government healthcare programs. Most of the cases were filed by individual whistleblowers under the False Claims Act’s qui tam provisions. The largest cases were brought against pharmaceutical and medical device companies. Glaxo Smith Kline paid $1.5 billion to settle allegations that it promoted off-label use of its drugs, which resulted in improper reimbursement from Medicare, Medicaid, and other government programs. Other examples of healthcare fraud this year involved hospitals, skilled nursing facilities, hospices, home healthcare agencies, and ambulance services. The largest False Claims Act settlements involving hospitals in 2012 were: Tenet Healthcare Corporation paid $43 million to settle allegations that it improperly billed Medicare for admissions to inpatient rehabilitation facilities that were not medically necessary. Hospital Corporation of America (HCA) paid $16.5 million to settle allegations that it violated the Stark Statute by entering into favorable leasing arrangements with doctors who referred patients to the hospital. Beth Israel Medical Center paid $13 million to settle allegations that it selectively inflated fees to get more "outlier payments." Freeman Health System paid $9.3 million to settle allegations that it violated the Stark Law by providing incentive pay to physicians who referred patients to the hospital system. Adventist Health System/Sunbelt Inc. paid $3.9 million to settle allegations that it improperly used billing modifiers and billed for services that were not actually provided. The False Claims Act allows private citizens to file suits on behalf of the government to recover three times the amount of false claims plus penalties of $11,000 per claim. The cases are filed under seal (in secret) to give the government an opportunity to conduct an investigation and decide whether to join the lawsuit. If the government recovers money from the defendants, the whistleblower, known as a relator, receives up to 30 percent of the recovery as a reward. Whistleblower rewards in Medicare and Medicaid fraud cases can reach hundreds of thousands of dollars and even millions of dollars. If you are aware that false claims are being submitted to Medicare or Medicaid, then you should consult with an experienced False Claims Act attorney immediately to protect your rights. To arrange a free and confidential consultation by phone or in person, call my office today at (917) 652-6504 or click here to contact me via email. John Howley, Esq. The information you obtain at this site is not, nor is it intended to be, legal advice. You should consult an attorney for advice regarding your individual situation. I invite you to contact our law offices and welcome your calls, letters and electronic mail. Contacting us does not create an attorney-client relationship. Please do not send any confidential information to us until such time as an attorney-client relationship has been established. I practice law and offer legal services only in jurisdictions where I am properly authorized to do so. I do not seek to represent anyone in any jurisdiction where this web site does not comply with applicable laws and bar rules. The words “Medicare Fraud” evoke images of hardened criminals creating false medical records to steal money from government healthcare programs. In fact, most “Medicare fraud” cases involve complicated allegations against large, legitimate institutions such as well-known hospitals and pharmaceutical companies. A good example is the recent $900,000 settlement by Baylor University to resolve allegations that its hospitals submitted false claims to Medicare, the Civilian Health and Medical Program of the Uniformed Services (TRICARE), and the Federal Employees Health Benefit Program (FEHBP). At issue were claims for intensity modulated radiation therapy (IMRT), a type of high-precision radiotherapy that uses computers to deliver precise doses of radiation to a malignant tumor or specific areas within the tumor. IMRT is used when extreme precision is required to avoid harming surrounding organs or healthy tissue. The government alleged that Baylor submitted improper claims for IMRT (an expensive procedure) when a different, less expensive procedure should have been billed. The government also alleged that Baylor failed to maintain supporting documentation in the medical records and did not provide corroboration of physician supervision. In other words, this was a dispute over professional medical judgments and record keeping. And it cost Baylor more than $1 million when its attorney’s fees are included in the settlement costs. Under the False Claims Act, the government is not required to prove that the hospital or other healthcare provider intended to defraud Medicare or another government program. Very severe penalties may be imposed if a court finds that the healthcare provider knew that a claim for reimbursement was not justified by medical necessity or was not supported by complete documentation. If a healthcare provider is found to have violated the False Claims Act, it must pay three times the amount the government paid on the allegedly false claims, plus a penalty of $11,000 per claim. The heathcare provider may also be excluded from future participation in government healthcare programs. Healthcare providers often choose to settle False Claims Act cases and refund some money instead of spending hundreds of thousands of dollars or more on legal fees to defend themselves at trial where a loss could mean a multi-million dollar judgment, exclusion from government healthcare programs, and adverse publicity. The key to resolving these types of disputes is getting expert advice from an experienced healthcare lawyer at the earliest possible stage of a government audit or investigation. A lawyer with intimate knowledge of reimbursement rules and regulations can help you work with auditors and investigators to explain your actions, answer their questions, and often resolve disputes before they become a federal case with the local prosecutor. If you are facing a government audit, investigation, or healthcare fraud charges, then you should consult with an experienced False Claims Act attorney immediately to protect your rights. To arrange a free and confidential consultation by phone or in person, call my office today at (917) 652-6504 or click here to contact me via email. John Howley, Esq. The information you obtain at this site is not, nor is it intended to be, legal advice. You should consult an attorney for advice regarding your individual situation. I invite you to contact our law offices and welcome your calls, letters and electronic mail. Contacting us does not create an attorney-client relationship. Please do not send any confidential information to us until such time as an attorney-client relationship has been established. I practice law and offer legal services only in jurisdictions where I am properly authorized to do so. I do not seek to represent anyone in any jurisdiction where this web site does not comply with applicable laws and bar rules. The Centers for Medicare & Medicaid Services (CMS) report that healthcare recovery auditors (RACs) collected $2.3 billion in overpayments from providers in fiscal year 2012. The recovery of overpayments sets a new record that is almost three times more than the $800 million in overpayments recovered in the prior year. RACs also identified almost $100 million in underpayments. The Medicare Recovery Audit Contractor (RAC) program is designed to identify improper Medicare payments - both overpayments and underpayments. RACs are paid on a contingency fee basis, receiving a percentage of the improper overpayments and underpayments they collect from providers. Audits may cover up to the prior three years of provider claims. The scope of the audit may include ambulance, durable medical equipment, hospital inpatient and outpatient, laboratory, physician, and skilled nursing facility services. Payment errors often involve duplicate payments, fiscal intermediaries' mistakes, medical necessity, and coding. While many RACs have focused primarily on hospitals, American Medical News reports that CMS will direct the auditors' scrutiny of physician practices as well. The specific targets for these audits will include the so-called high-level patient evaluation code. John Howley, Esq. The information you obtain at this site is not, nor is it intended to be, legal advice. You should consult an attorney for advice regarding your individual situation. I invite you to contact our law offices and welcome your calls, letters and electronic mail. Contacting us does not create an attorney-client relationship. Please do not send any confidential information to us until such time as an attorney-client relationship has been established. I practice law and offer legal services only in jurisdictions where I am properly authorized to do so. I do not seek to represent anyone in any jurisdiction where this web site does not comply with applicable laws and bar rules. The Supreme Court of New Hampshire upheld a state law requiring that juries be told the findings of “pretrial medical screening panels.” The panels consist of a retired judge, an attorney, and two physicians who review medical malpractice cases before proceeding to court. At least 16 states have medical screening panels. A 2008 study by Pinnacle Actuarial Resources for the American Medical Association found that states with screening panels had lower medical liability insurance rates — 20% below the national average — and lower claims costs than states without such laws. In this case, Sheila Parker’s family sued for medical malpractice after she entered a hospital complaining of back pain and later died of meningitis. According to court documents, Parker was seen by an emergency room physician, who diagnosed her with intractable pain and admitted her to the hospital. Some time later, a neurosurgeon initiated a lumbar puncture, which showed that she had meningitis. She was taken to the intensive care unit and given antibiotics, but her condition deteriorated and she died. Parker’s family claimed that the hospital should have brought in a neurosurgical specialist earlier and that a delayed diagnosis, combined with late treatment, contributed to her death. A pretrial medical screening panel reviewed the evidence and unanimously found that the defendants’ actions did not “constitute a deviation from the applicable standard of care.” The trial court, however, refused to disclose the panel’s findings to the jury. On appeal, the state Supreme Court reversed and upheld the law requiring juries to be told of the panel’s findings. The Court wrote that “the Legislature has the authority to deem certain evidence relevant and admissible because, like the judiciary, it has the authority to create evidentiary rules.” However, the Court also ruled that the jury may hear the evidence that was presented to the panel, including testimony from experts who had testified at the panel proceeding. While the jury may consider the panel’s rulings as evidence, the jury must make its decision based on all the evidence presented. John Howley, Esq. The information you obtain at this site is not, nor is it intended to be, legal advice. You should consult an attorney for advice regarding your individual situation. I invite you to contact our law offices and welcome your calls, letters and electronic mail. Contacting us does not create an attorney-client relationship. Please do not send any confidential information to us until such time as an attorney-client relationship has been established. I practice law and offer legal services only in jurisdictions where I am properly authorized to do so. I do not seek to represent anyone in any jurisdiction where this web site does not comply with applicable laws and bar rules. |
John Howley, Esq.
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