Most people just want to do their jobs and go home to their families at the end of the day. Unfortunately, if your boss is committing health care fraud, it may not be that simple. Consider the physician's assistant who is now facing up to five years in prison because he followed his doctor's instructions. Cal Graves was a 31 year old physician's assistant at the South Dallas Community Medical Center. The owner of the center, Dr. Daniel K. Leong, is about to go on trial for Medicare and Medicaid Fraud. According to court papers, Dr. Leong signed a blank prescription form and instructed Cal and other staff members to copy and use this pre-signed prescription as needed -- even when Dr. Leong never saw the patient. Patients had their prescriptions filled at pharmacies, which then submitted claims to Medicare and Medicaid for reimbursement. However, Medicare and Medicaid would not have paid those claims if they had known that Dr. Leong never saw the patient. When the government discovered the scheme, it arrested Dr. Leong for health care fraud. The government also arrested his physician's assistant, Cal Graves, for conspiracy to commit health care fraud because, by going along with the doctor's instructions, Cal helped execute the fraudulent scheme. Now Cal faces a maximum statutory sentence of five years in prison and a $250,000 fine. Sadly, good people get into this type of trouble all the time. A physical therapist goes along with her administrator's instructions to extend patient treatments beyond what is medically necessary and ends up charged with conspiracy to commit Medicare Fraud. A billing clerk follows her supervisor's instructions to "upcode" claims (i.e., use a code for a different service that results in a higher reimbursement) and ends up charged with conspiracy to commit Medicaid Fraud. A nurse goes along with the doctor's instructions to refer patients to a particular diagnostic lab that pays the doctor for each referral, and the nurse ends up charged with a felony for violating the Anti-Kickback statute. If you think no one will find out, think again. The government has very sophisticated computer systems that constantly monitor Medicare and Medicaid claims for suspicious patterns. It also has Medicare Fraud Strike Forces staffed with FBI agents and other experienced investigators around the country. And it pays out hundreds of millions of dollars in bounties every year to whistleblowers -- individuals who help the government uncover false and fraudulent claims in return for a percentage of the amount recovered. Protect yourself and get expert advice. Do not end up like Cal, facing five years in prison for doing nothing more than following instructions. If you become aware of false, dishonest or fraudulent conduct at work, then you should consult with an experienced attorney immediately to protect your rights. To schedule a free initial consultation by telephone or in person, call my office today at (917) 652-6504 or click here to communicate with me via email. You do not have to face this alone. John Howley New York, New York 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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Urgent Care Facility Agrees to Pay $10 Million to Settle Alleged False Claims Act Violations7/16/2012 An Arizona-based company, has agreed to pay $10 million to settle allegations that it submitted false claims for unnecessary testing and inflated charges. The company owns a chain of urgent care facilities in Arizona, Colorado, Texas, North Carolina, Ohio and Virginia. At issue are allegedly false claims for allergy, H1N1 virus, and respiratory panel testing submitted to Medicare, TRICARE, the Federal Employees Health Benefits Program, as well as the Medicaid programs of Colorado, Virginia, Texas, North Carolina and Arizona, by billing for unnecessary. The government also alleged that it inflated billings for urgent care medical services, a practice known as upcoding. The allegations were initially raised by a former employee who initiated a qui tam suit under the False Claims Act. The Act allows individual citizens, known as "relators," to bring suit on behalf of the United States and share in the recovery. The relator in this action will receive $1.614 million. In addition to the payment of $10 million, the settlement also involves a Corporate Integrity Agreement with the Department of Health and Human Services, Office of Inspector General, under which the company will be monitored for five years to ensure future compliance with all federal healthcare program rules. John Howley, Esq. New York, New York 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 federal government recovers more than $4 billion every year under the False Claims Act, with more than 80% of cases involving pharmaceutical companies, medical professionals, and other healthcare-related defendants. These are complex cases that often involve claims for treble damages and penalties, potential exclusion from government programs, qui tam actions brought by private plaintiffs, and parallel criminal investigations and prosecutions. Lawline.com now offers a Continuing Legal Education (CLE) program on this rapidly developing area of the law. Entitled The False Claims Act: Enforcement Trends in Health Care, the program examines enforcement trends since the Fraud Enforcement and Recovery Act of 2009 and the Patient Protection and Affordable Care Act of 2010. The program also examines significant changes in enforcement policies and initiatives in the Obama Administration. Topics covered include:
John Howley, Esq. New York, New York Regional Hospital Settles False Claims Act Allegations for $3.6 Million After Voluntary Disclosure6/30/2012 Maury Regional Medical Center in Nashville, Tennessee has agreed to pay $3.6 million to settle False Claims Act allegations that it overcharged Medicare for ambulance services. After the 275-bed hospital’s compliance program discovered that some ambulance trips had been made for medically unnecessary issues and that the paperwork for some trips was incomplete or incorrect, the hospital voluntarily disclosed the overcharges to the local U.S. Attorney and the Office of Inspector General for the Department of Health and Human Services. Based upon an audit of billings conducted by Maury Regional, the government alleged that medical center submitted certain claims and received payment for: (1) ambulance services that were not medically necessary or for which medical necessity was not documented; (2) ambulance services for which a Physician Certification Statement was not obtained; (3) ambulance services that were assigned an incorrect transport level; (4) ambulance services for which the requisite signatures were not obtained; and (5) ambulance services that were billed with incorrect mileage units. The time period covered by the settlement agreement spans January 1, 2004, through December 31, 2009. The hospital blamed an outside company that processed billing for ambulance transport claims with Medicare. Those billing functions have since been brought in house. The government commended Maury Regional for making the disclosure and for working closely with enforcement agencies to resolve the problems now and going forward. John Howley, Esq. New York, New York Government Pays Whistleblowers Millions in False Claims Act Cases When Wellcare Health Plans agreed to pay $137.5 million to settle Medicaid fraud allegations, a former employee who blew the whistle became a wealthy man. Under the qui tam provisions of the federal False Claims Act, former Wellcare financial analyst Sean Hellein will be paid $20.75 million for initiating the lawsuit that led to the government's investigation and settlement. This is just one of many False Claims Act lawsuits that have resulted in large rewards for whistleblowers. Other recent cases include:
The Act contains a qui tam provision that allows a private person to initiate a lawsuit on behalf of the United States government. Qui tam is short for the Latin phrase “qui tam pro domino rege quam pro se ipso in hac parte sequitur,” which is loosely translated as "he who sues in this matter for the king as well as for himself." Here’s how it works: A private person, known as a “relator,” commences a lawsuit on behalf of the United States government to recover damages caused by the submission of false or fraudulent claims. The qui tam complaint must be filed under seal, which means that all records relating to the case must be kept in a secret docket in the court. Copies of the complaint are given only to the U.S. Department of Justice (DOJ), the local U.S. Attorney, and the assigned Judge. In addition to the complaint, the relator must give the Department of Justice a “disclosure statement” containing all the evidence supporting the allegations in the complaint. The disclosure statement is not filed in any court and is not available to the named defendant. The relator must be represented by a lawyer. The lawyer will assist the relator in pulling together the evidence, preparing the complaint and disclosure statement, and complying with the many procedural and technical requirements. The DOJ must investigate the allegations of false or fraudulent claims. At the conclusion of the investigation, the DOJ must either (a) intervene in the lawsuit and participate as a plaintiff prosecuting the case; (b) decline to intervene; or (c) move to dismiss the complaint either because there is no case or the case conflicts with significant interests of the United States. In practice, the DOJ often settles the lawsuit with the defendant before formally intervening (in which event, the relator will be entitled to a percentage of the settlement) or advises the relator that the government will not intervene (in which case the relator and relator’s counsel must decide whether to pursue the case on their own or dismiss it). Other than money and a desire to do the right thing, why would anyone volunteer to be a whistleblower? Self-preservation is another factor. Anyone who knowingly assists in the submission of false or fraudulent claims to the government is at risk of being prosecuted for a crime along with their employer. For example, when a physician in Texas was arrested recently on Medicare fraud charges, the physician’s billing clerk was also arrested and now faces criminal charges. The billing clerk may wish today that he had become a whistleblower instead of following his employer's lead. If you are aware that false or fraudulent claims have been submitted to the government, then you should consult with an experienced attorney immediately to protect your rights. To schedule a free initial consultation by telephone or in person, call our office today at (917) 652-6504 or click here to communicate with us via email. John Howley, Esq. New York, New York 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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