Pharmacists allegedly gave doctors rent and office staff in return for patient referrals and medically unnecessary prescriptions.
Two New York pharmacists have been arrested and charged with submitting false and fraudulent claims to Medicare and Medicaid for medically unnecessary prescriptions and over-the-counter products that were not actually dispensed. The indictment also charges the pharmacists with paying illegal kickbacks to doctors and patients.
The Anti-Kickback Statute prohibits offering, paying, soliciting, or receiving anything of value in exchange for referrals of items or services reimbursable by Medicare, Medicaid, or other federally-funded healthcare programs. The law was enacted to prevent healthcare providers from using financial incentives to encourage unnecessary or inappropriate medical treatment and services, which can lead to fraud and abuse in government healthcare programs.
The Anti-Kickback Statute applies to all healthcare providers who participate in federal healthcare programs, including doctors, pharmacists, hospitals, nursing homes, and medical device manufacturers.
Kickbacks to Doctors in the Form of Rent and Office Staff
The indictment asserts that the two pharmacists conspired with others to pay illegal kickbacks to doctors in the form of rent and office staff in return for medically unnecessary prescriptions filled at their pharmacies.
Under the Anti-Kickback Statute, pharmacists are prohibited from offering anything of value to healthcare providers, such as doctors or nurses, in exchange for referrals of patients who need prescription medications. “Anything of value” means what it says and is not limited to money. It also includes free or subsidized rent, office staff, and other non-monetary benefits.
While it is possible for doctors and pharmacists to enter into financial arrangements or relationships with one another, any such arrangement or relationship must be based on fair market value and may not be tied to the volume or value of patient referrals.
Kickbacks to Patients in the Form of Cash and Gift Certificates
According to the indictment, the two pharmacists also conspired with others who gave cash and supermarket gift certificates to Medicare and Medicaid recipients in return for filling prescriptions at their pharmacies.
Under the Anti-Kickback Statute, pharmacists and other healthcare providers are prohibited from offering anything of value in exchange for referrals of items or services reimbursable by federal healthcare programs, such as Medicare or Medicaid.
There are limited exceptions and safe harbors that allow for certain types of gifts or arrangements that are not considered kickbacks. For example, a pharmacist may give patients gifts of minimal value that are not intended to induce patients to use a particular pharmacy. Gifts that are of nominal value, such as promotional items like pens, notepads, calendars, or other items that are worth less than $15 are generally permissible under the nominal value exception.
However, even gifts of nominal value must meet certain conditions to avoid violating the Anti-Kickback Statute. For example, the gift must not be conditioned on the patient’s purchase of a particular medication or service, and the gift must not be given in exchange for the patient’s referral or business.
Whistleblower Rewards for Reporting Kickbacks to Doctors and Patients
The penalties for violating the Anti-Kickback Statute are severe. In this case, the pharmacists face a maximum penalty of 10 years in prison for conspiracy to commit health care fraud, 20 years in prison for conspiracy to commit money laundering, and five years in prison for conspiracy to pay illegal health care kickbacks and bribes.
Kickbacks, however, are difficult to detect and prove. For that reason, the government pays financial rewards to whistleblowers who help discover and prove kickback schemes designed to defraud Medicare and Medicaid.
The rewards range from 15% to 30% of the amount recovered by the government. This often results in whistleblowers earning hundreds of thousands of dollars in rewards, and sometimes millions of dollars in reward money.
For example, in this case, the pharmacists are accused of submitting $26 million in false claims to Medicare and Medicaid as a result of the kickback scheme. The potential whistleblower reward, therefore, is between $3.9 million and $7.8 million.
If you have evidence of kickbacks being paid to doctors or patients who benefit from Medicare or Medicaid, you should contact 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 with an experienced whistleblower lawyer, call us today at (212) 601-2728.
How Patients Earn Whistleblower Rewards by Studying Their Explanations of Benefits (EOBs)
Most people think whistleblowers have to be company insiders. That is not always the case. We often represent patients who discover overbilling on their Medicare Advantage Plan’s Explanation of Benefits (EOB) forms. By paying attention to those EOBs, patients can help the government uncover massive frauds.
Plus, as whistleblowers, patients can earn rewards worth hundreds of thousands of dollars and, sometimes, even millions of dollars.
Take the recent case of two men who submitted more than $3.8 million in false claims to Medicare Advantage and Medicaid managed care plans.
The owner and manager of a durable medical equipment supplier in New York billed Medicare Advantage and Medicaid managed care plans for hundreds of expensive patient support systems. These support systems included large devices that were designed to assist with lifting immobile patients and patients in nursing homes.
The men, however, did not actually provide the expensive support systems. Instead, they gave patients recliner chairs that had a seat lift feature. Between December 2010 and February 2014, the two men fraudulently billed Medicare Advantage and Medicaid managed care plans more than $3.8 million and were paid approximately $2.4 million.
It is almost impossible for the government to discover this type of fraud on its own. Every year, the government processes 1.2 BILLION fee-for-service claims for more than 33.9 million Medicare beneficiaries who receive health care benefits through the Original Medicare program. That is more than 3,000,000 (Three Million) claims every day. And that doesn’t include claims for reimbursement processed by Medicare Advantage, Medicaid, and Medicaid managed care plans.
With such a large number of claims being filed every day, the government cannot check every delivery to find out what the patients actually received. That’s where the patients come in. To ensure that patients are actually receiving the products and services that the government is paying for, the government needs patients to review their EOBs.
Most people only look at the EOBs to find out how much they have to pay. If the number is small or zero, they don’t bother looking at the details. Fortunately, our clients take the time to look at the details.
Over the years, our clients have earned millions of dollars in whistleblower rewards uncovering fraudulent billing for durable medical equipment, dental procedures, hyperbaric oxygen therapy, home healthcare services, urgent care center treatment, pharmaceuticals, and many other healthcare products and services.
So, what happened with the two men who fraudulently billed the government for expensive support systems when they were delivering only recliner chairs? They have been convicted and have to pay back all the money they received plus penalties.
If you have evidence of false or inflated claims being submitted to your Medicare Advantage plan, you should consult with an experienced whistleblower lawyer right away. You may be entitled to a whistleblower reward of between 15% and 30% of the amount the government recovers. But do not delay. Only the first whistleblower is entitled to a reward.
To schedule a free and confidential consultation with an experienced whistleblower lawyer, call us today at (212) 601-2728.
John Howley, Esq.
Under federal and state laws, a pharmacy that fills prescriptions for Medicaid beneficiaries may not charge the government more than the drug’s “usual and customary” price. The whistleblower in this case came forward with evidence that Walgreens charged government programs more for prescription drugs than it charged some customers who were enrolled in the company’s Prescription Savings Club (“PSC”).
After the whistleblower filed a qui tam or whistleblower lawsuit “under seal” (that is, in secret), the government conducted an investigation using the evidence he provided. Walgreens ultimately settled the fraud claims by agreeing to pay back $60 million to federal and state Medicaid programs. As part of the settlement, the company admitted that the government “paid Walgreens more money in reimbursements than they would have paid if Walgreens had identified its PSC prices as its [usual and customary] prices.”
It is unlikely that the fraud would have been discovered without help from a whistleblower on the inside. This case demonstrates the power of a single individual to save the government – and taxpayers – tens of millions of dollars by coming forward with evidence of fraudulent claims. It is also another example of the significant rewards that are available to whistleblowers who help the government uncover fraud, waste, and abuse in our healthcare programs.
The whistleblower laws, however, are complicated. This is not something a whistleblower can or should handle on their own. If you have evidence of false claims submitted to Medicare or Medicaid, then you should consult with an attorney immediately to understand and protect your rights.
To schedule a consultation with an experienced whistleblower lawyer, call John Howley, Esq. at (212) 601-2728.
The former billing manager for MedStar Ambulance, Inc. will receive a $3.5 million whistleblower reward for reporting overbilling at the ambulance company.
MedStar has agreed to pay $12.7 million to settle the whistleblower’s claims that it billed Medicare for unnecessary ambulance services. The whistleblower’s complaint alleged that the company billed Medicare for ambulance services that were not medically necessary, that were billed at higher levels of services than patients’ conditions required, and that were billed at higher levels of services than were actually provided.
One of the schemes involved billing Medicare for routine trips to a doctor’s appointment or nursing home as if they were emergency runs in order to receive higher Medicare reimbursements. The whistleblower also reported that the company double-billed patients and Medicare, and that it billed Medicare when it should have billed hospitals or municipalities.
The whistleblower brought his claims under the qui tam provisions of the False Claims Act. He filed a complaint “under seal” (i.e., in secret) in federal court and handed over all of his evidence to the U.S. Attorney. The government then used his evidence to conduct an investigation and pursue claims against the company.
The False Claims Act provides that a whistleblower is entitled to a reward of between 15% and 30% of the amount the government actually recovers. In this case, the whistleblower will receive $3.5 million, or approximately 28% of the government’s recovery.
If you have evidence of overbilling or false claims submitted to Medicare or Medicaid, then you should consult with an experienced whistleblower lawyer immediately to protect your rights. There are strict time limits and procedural requirements to preserve your claim.
Call John Howley, Esq. at (212) 601-2728 to schedule a free and confidential consultation.
Chiropractors Face Major Changes in Medicare Billing and Reimbursement Rules
An audit of chiropractic services billed to Medicare has concluded that more than 80% of the claims for reimbursement should not have been approved or paid. The audit was conducted by the Office of Inspector General (OIG) at the U.S. Department of Health and Human Services.
Based on a sampling of Medicare claims, OIG estimated that $358.8 million of the $438.1 million paid by Medicare for chiropractic services should not have been paid. In other words, OIG concluded that 82% of Medicare claims for chiropractic services were not valid. According to OIG, the overpayments occurred primarily because chiropractors billed for a high number of medically unnecessary services.
OIG recommended that the Centers for Medicare and Medicaid Services (CMS) institute strong controls to prevent improper payments for chiropractic services in the future. Among the suggested controls is a limit on the number of chiropractic services that Medicare will reimburse (such as no more than 30 per beneficiary per year), and a system that would automatically disallow services in excess of that limit.
The high percentage of overpayments means that the government will be looking very carefully at Medicare claims for chiropractic services from now on. The government will also be very interested in whistleblowers who come forward with evidence of excessive or medically unnecessary chiropractic services billed to Medicare.
Under the False Claims Act, individuals who come forward with evidence of false claims submitted to Medicare or Medicaid are entitled to substantial financial rewards and legal protections. The whistleblower rewards range from 15% to 30% of the amount the government recovers from the healthcare provider. Whistleblower rewards can reach hundreds of thousands of dollars and sometimes millions of dollars.
To qualify as a whistleblower you must comply with very strict procedural and confidentiality requirements. One misstep and you could lose your eligibility for a reward and legal protections. If you have evidence of false claims submitted to Medicare or Medicaid, then you should consult with an experienced whistleblower attorney immediately, before your contact the government, to protect your rights.
You can schedule a free and confidential consultation with an experienced whistleblower lawyer by calling John Howley Esq. at 212-601-2728.
Whistleblowers Who Report False or Inadequately Documented Medicare Claims for Hyperbaric Oxygen Therapy Treatments Are Entitled to Financial Rewards.
The U.S. Department of Health and Human Services (HHS) has announced that investigating false claims for Hyperbaric Oxygen Therapy will be a top priority in 2017. The announcement was made as part of the HHS Office of Inspector General’s 2017 Work Plan.
Hyperbaric oxygen (HBO) therapy involves giving a patient high concentrations of oxygen within a pressurized chamber. Breathing 100 percent oxygen intermittently in a pressurized chamber has been found to be an effective adjunctive treatment for the management of some non-healing wounds.
Medicare provides reimbursement for HBO therapy under certain circumstances. The HHS Office of Inspector General (OIG) has expressed concern, however, that Medicare has reimbursed hospitals and other HBO therapy providers for claims that should not have been paid.
The specific concerns are patients who received HBO treatments for non-covered conditions, patients who received more HBO treatments than were medically necessary, and Medicare claims for HBO treatments that were not supported by adequate medical documentation.
Medicare provides reimbursement for HBO therapy only when the patient has one of the following conditions: Acute carbon monoxide intoxication; Decompression illness; Gas embolism; Gas gangrene; Acute traumatic peripheral ischemia; Crush injuries and suturing of severed limbs; Progressive necrotizing infections (necrotizing fasciitis); Acute peripheral arterial insufficiency; Preparation and preservation of compromised skin grafts; Chronic refractory osteomyelitis; Osteoradionecrosis; Soft tissue radionecrosis; Cyanide poisoning; Actinomycosis; and Diabetic wounds of the lower extremities in patients who meet the following
three criteria: (a) Patient has type I or type II diabetes and has a lower extremity wound that is due to diabetes; (b) Patient has a wound classified as Wagner grade III or higher; and (c) Patient has failed an adequate course of standard wound therapy.
Because HBO therapy is covered as an adjunctive therapy, the supporting medical documentation must establish not only the patient’s condition, but also the patient’s response to standard treatments. HBO therapy is covered only after there are no measurable signs of healing for at least 30 days of treatment with standard wound therapy.
The supporting medical documentation must also demonstrate that the HBO therapy is having measureable results. Wounds must be evaluated at least every 30 days. Continued treatment with HBO therapy is not covered if measurable signs of healing have not been demonstrated within any 30-day period of treatment.
Even if the patient satisfies all the criteria for reimbursement, a claim for reimbursement from Medicare will be considered “false” if the contemporaneous medical documentation does not establish that the patient has been diagnosed with one of the covered conditions, standard wound therapy has not resulted in measureable results for at least 30 consecutive days, and HBO therapy has resulted measureable signs of healing.
Failing to maintain the proper documentation can result in severe penalties, including paying restitution of up to three times the amount Medicare paid and penalties of up to $11,000 per claim. In cases of intentional fraud, criminal charges are possible.
The government cannot uncover false or inadequately documented claims on its own. For that reason, the government provides significant financial incentives and legal protections to whistleblowers. Individuals who come forward with evidence of false or inadequately documented claims to Medicare are entitled to a reward of up to 30% of the amount the government recovers from the HBO therapy provider.
Whistleblowers, however, must follow strict procedural requirements to be eligible for a reward. If you have evidence of false or inadequately documented Medicare claims for HBO therapy, you should consult with an experienced whistleblower lawyer immediately to protect your rights. Call John Howley, Esq. at (212) 601-2728 to schedule a free and completely confidential consultation.
Pay Careful Attention to Your Explanation of Benefits (EOBs)
When we think of whistleblowers, we usually think of corporate insiders who have access to secret documents and records. In healthcare, however, patients are the ultimate insiders.
Patients have a powerful weapon to fight Medicare and Medicaid fraud. It is called their Explanation of Benefits (EOB).
EOBs explain what charges were billed to the insurance program, how much was allowed or disallowed, how much was paid to the provider, and how much, if any, the patient must pay themselves.
Many patients only look at the last category to see how much, if anything, they must pay. That is exactly how fraudsters like it.
Patients who take the time to read their EOBs carefully may be surprised at what they find. Patients often find mistakes, charges for services that were not provided, double billing, and other types of Medicare and Medicaid fraud.
We have represented a number of patients who uncovered false claims to Medicare and Medicaid by studying their EOBs. Several have received whistleblower rewards for helping the government uncover improper charges.
Some of our clients found that the government was charged for services that were not provided. Others found that the government was charged for an expensive, complicated service, when the patient actually received a basic check-up.
Another common fraud that can be caught by reviewing your EOBs is double-billing. In its simplest form, a healthcare provider asks you to make a payment because your service is not covered by Medicare or Medicaid. After you make the payment, however, the EOB shows that Medicare or Medicaid paid the provider again for the same service.
If you look only at the bottom line on the EOB – which says that you owe nothing – you might miss the fact that the provider was paid twice for the same service, once by you and again by the government.
Obviously, you are entitled to a refund under these circumstances. You may also be entitled to a substantial whistleblower reward if you follow the proper procedures to report the double billing to the government.
A claim for reimbursement is considered a “false claim” if the provider was already paid by the patient. When you report a false claim to the government using the False Claims Act, the government will investigate to determine whether this was a mistake or whether the provider is double billing patients on a regular basis.
A provider that double bills on a regular basis will be liable for three times the amount they were paid, plus a penalty of up to $11,000 per claim. That can add up to millions of dollars.
As a whistleblower, you are entitled to a reward of between 15% and 30% of the amount actually recovered.
If you find improper charges on your EOB, you should consult with an experienced whistleblower lawyer immediately to protect your rights. There are strict procedural requirements and time limits to qualify for a whistleblower reward.
To schedule a free and confidential consultation with a whistleblower lawyer, call John Howley, Esq. at (212) 601-2728.
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.
Whistleblowers Are Urgently Needed to Stop this Type of Massive Fraud
The government has charged three individuals with a conspiracy to collect more than $1 Billion from Medicare and Medicaid for services that patients did not require or were not eligible to receive. The three individuals are the owner of more than 30 nursing homes and assisted living facilities, a hospital administrator, and a physician’s assistant.
Yes, you read that correctly. Three individuals are accused of stealing more than $1 Billion from Medicare and Medicaid.
According to the FBI, the three individuals were the leaders of a complex conspiracy that included filing false claims with the help of other healthcare providers, and an intricate money laundering scheme designed to hide the flow of payments and kickbacks.
The indictment charges that Philip Esformes operated a network of more than 30 nursing homes and assisted living facilities that provided services to thousands of patients. Esformes and his co-conspirators allegedly billed Medicare and Medicaid for medically unnecessary services for many of these patients.
The co-conspirators are also charged with receiving kickbacks in return for steering residents to other healthcare providers, who provided additional, medically unnecessary services. The kickbacks allegedly were paid in cash or were disguised as payments for leases, services, or charitable donations to avoid discovery.
This case illustrates the critical importance of whistleblowers to uncover billions of dollars in healthcare fraud, waste, and abuse.
The government receives millions of claims every day for reimbursement from Medicare, Medicaid, and other government healthcare programs. The claims often set forth nothing more than the patient’s and provider’s identifying information, billing and diagnostic codes, an actual or electronic signature, and a request for payment. Without help from a whistleblower on the inside, it is impossible for the government to determine whether the services were medically necessary, whether they were actually provided to the patients, or whether improper kickbacks were exchanged in return for patient referrals.
If you have evidence of Medicare or Medicaid fraud, it is your patriotic duty to come forward and stop the fraud. In return, you are entitled to legal protections and a reward of up to 30% of the amount recovered by the government. In Medicare and Medicaid fraud cases, it is not unusual for those rewards to reach millions of dollars.
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 in order to qualify for a whistleblower reward.
Drayer Physical Therapy Institute, LLC has agreed to pay $7 million to settle allegations that it submitted false claims to Medicare, TRICARE, and Federal Employee Health Benefit Programs.
Two former employees brought a whistleblower or qui tam lawsuit against the company under the False Claims Act. The whistleblowers alleged that the company provided services to multiple patients simultaneously, but then billed the government at the much higher rate for services provided by a physical therapist to one patient at a time.
The False Claims Act allows individuals to file healthcare fraud lawsuits on behalf of the government and share in any recovery. In this case, the two whistleblowers will share 24% of the settlement payment, or approximately $1.7 million.
This reward is based on the amount and quality of evidence the whistleblowers brought to the government, as well as their willingness to help the government during an investigation of their claims.
As this case illustrates, whistleblowers are essential to the government’s efforts to crack down on multi-million dollar frauds. Without the help of whistleblowers, it is virtually impossible for the government to uncover this type of fraud. Only insiders know both what type of treatment the patients received and how that treatment was billed to the government.
If you have evidence of false claims submitted to Medicare or Medicaid, then you should consult with an experienced whistleblower lawyer immediately. You will help stop fraud and waste in the healthcare system. You may also be entitled to legal protections and a substantial financial reward as a whistleblower.
Do not delay. There are strict time limits and procedural requirements to claim a whistleblower reward. Call John Howley, Esq. at (212) 601-2728 today to schedule a free and confidential consultation with an experienced whistleblower lawyer.
John Howley, Esq.
The Howley Law Firm P.C.
350 Fifth Avenue, 59th Floor
New York, New York 10118