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What Payers Are Considered to Be “Federal Payers” Under the Federal Anti-kickback Statute?

By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

The federal Anti-Kickback Statute prohibits remuneration in relation to the provision of a “good, facility, service, or item for which payment may be made in whole or in part under a Federal health care program.” 42 U.S.C. § 1320a-7b(b). The Anti-Kickback Statute goes on to define “federal health care program” as any government-funded plan or program that provides health benefits or any state health care program. 42 U.S.C. § 1320a-7b(f). But exactly which payers are considered Federal health care programs? There is a lot of confusion on this issue. Hopefully, this will clarify it.

The List of Federal Payers for To Which the Anti-Kickback Statute Applies.

The list of federal and state programs to which the Anti-Kickback Statute applies is a long one. The state ones are on there primarily because they receive some level of federal funding. This list includes many programs, some of which you may have never heard or guessed. Here are the ones of which I am aware:

The Medicare Program (along with managed care plans that may contract with the Medicare Program, a number of private insurers);

The Medicaid Program (along with managed care plans that may contract with the various state Medicaid Programs-the private insurers which do this);

State Children’s Health Insurance Program (CHIP or SCHIP);

TRICARE and Tricare for Life;

CHAMPVA;

Veterans Administration (VA) Services;

Indian Health Services (IHS);

Federal Health Program for Alaska Natives;

Railroad Employees National Health and Welfare Plan (RENHWP);

Federal Employees’ Compensation Act (FECA) program;

The Longshore and Harbor Workers’ Compensation Act (LHWCA);

The Federal Black Lung Benefits Act program (FBLBA);

The Energy Employees Occupational Illness Compensation Program Act (EEOIC) (also known as the “Beryllium Exposure Compensation Act”) program;

Refugee Medical Assistance (RMA) program;

Federal Reimbursement of Emergency Health Services to Undocumented Aliens program; and

The Ryan White HIV/AIDS Program.

These programs cover a very wide swath of all health services offered in the United States. Therefore, nearly every medical item, facility, service, or equipment is potentially payable by a federal health care program.

Note, however, the Federal Employee Health Benefit (FEHB) Program, the program that provides insurance and benefits to federal civilian employees, is not included in the above list of payers, by statutory exemption. 42 U.S.C. § 1320a-7b(f); 5 U.S.C. Ch. 89.

The Public Health Service (PHS) and its programs may also be excluded from the application. See 42 U.S.C. § 1320a-7b(b)(3)(D).

Cross-over with the False Claims Act.

Compliance with the Anti-Kickback Statute is a Condition of Payment for federal health care programs. Every claim that is submitted for payment contains an attestation that the provider providing the goods or services for which payment is sought has complied with the federal Conditions of Payment.” Therefore, if there has been a kickback in relation to such goods or services for which a claim is made, the False Claims Act will also apply.

Contact Health Law Attorneys Experienced with Health Care Fraud, False Claims Act Violations, and Anti-Kickback Statute Violations.

The attorneys of The Health Law Firm represent healthcare providers in cases of medical billing fraud, overbilling, Medicare audits, Integrity Contractor audits and RAC audits, False Claims Act cases, and whistleblower/qui tam cases throughout Florida and across the United States. Our attorneys also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.

To contact The Health Law Firm, please call (407) 331-6620 or toll-free at (888) 331-6620 and visit our website at www.TheHealthLawFirm.com.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Avenue, Suite 1000, Altamonte Springs, FL 32714, Phone: (407) 331-6620 or Toll-Free: (888) 331-6620.

Attorney Positions with The Health Law Firm. The Health Law Firm is always looking for qualified attorneys interested in the practice of health law. Its main office is in the Orlando, Florida, area. If you are a member of The Florida Bar and are interested, forward a cover letter and your resume to: KBrant@TheHealthLawFirm.com or fax to: (407) 331-3030.

“The Health Law Firm” is a registered fictitious business name of and a registered service mark of The Health Law Firm, P.A., a Florida professional service corporation, since 1999.

Doctor Indicted in $1.3 Million Medicare Fraud Kickback Case Seeks Reinstatement of Medicare Billing Privileges

By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

On November 2, 2021, a doctor and his wife who had been indicted for their roles in a $1.3 million Medicare fraud scheme asked a New Jersey court to eliminate a bail condition. The doctor argued that the bail condition impeded his ability to practice medicine. Additionally, the doctor indicated that he was seeking to directly address CMS and the Medical Practice’s ability to bill Medicare and Medicaid.

According to the brief, the defendants argued that the court should not get involved in a licensed physician’s medical practice. They argued that this is the role of the state board of medicine.

Background of Their Case.

Both of the defendants, in this case, were arrested and charged in July 2020 for accepting bribes and kickbacks in exchange for ordering unnecessary genetic tests for patients. Genetic testing has turned out to be the latest area of large-scale health care fraud. According to the Department of Justice (DOJ), the scheme billed Medicare for a total of $1.3 million for unnecessary tests. Both of the defendants had been released on $250,000 unsecured personal recognizance bonds.

Click here to view the press release issued by the DOJ.

Is It Really Possible?

In a brief filed with the court, the doctor and his spouse specifically asked the judge to allow them to submit claims to the federal government for reimbursement and to allow the referral of patients to certain other providers.

The defendants argued that because CMS had already suspended both individuals from submitting claims, the court’s bail conditions were unnecessary. The defendants wanted to be able to approach CMS and attempt to have the medical practice’s ability to continue billing the Medicare and Medicaid Programs reinstated. They contended that certain safeguards could be put into place if the practice were allowed to do so. The brief further argued that to the extent, the court had the concern that they would continue to submit fraudulent billing, the following arguments would prevent that:

1. A proposed third-party management company and a third-party billing company, with appropriate peer review, would take over all management and billing responsibilities;

2. CMS would need to agree to reinstate the medical practice with whatever conditions and restrictions it felt necessary before the practice submitted any additional Medicare or Medicaid claims;

3. It is already a condition of their bail that the defendants commit no further crimes.

These defendants’ brief argued that these safeguards should adequately address any concerns of possible future wrongdoing.

Defendants Say Bail Conditions Are Unreasonable For a Working Medical Practice.

The defendants claim the court’s order makes it practically impossible for the doctor to keep his Pennsylvania medical practice open. They claimed that the doctor treats a sizable Medicare and Medicaid patient population. It also argued that, as a licensed physician, he must continue treating his existing patients. Lastly, the defendants argued that they are hoping to eliminate a condition which they claim forces the medical practice to choose between meeting required standards of patient care or violating the court’s bail order.

What Was The Court’s Decision?

These all seemed like some pretty well-thought-out arguments that the defendants made. What did the court finally decide on this matter? Unfortunately, you will have to tune in to this blog at a later date to find out. Hopefully, the answer will not be lost in chaos.

Click here to view the defendant’s brief in full.

To read about another recent case involving bribery and kickbacks in a healthcare fraud scheme, click here to read one of my prior blogs.

Contact Health Law Attorneys Experienced with Health Care Fraud, False Claims Act Violations, and Anti-Kickback Statute Violations.

The attorneys of The Health Law Firm represent healthcare providers in cases of medical billing fraud, overbilling, Medicare audits, program integrity Contractor audits, False Claims Act cases, and whistleblower/qui tam cases throughout Florida and across the United States. Our attorneys also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.

To contact The Health Law Firm, please call (407) 331-6620 or toll-free at (888) 331-6620 and visit our website at www.TheHealthLawFirm.com.

Sources:

Pagan, McCord. “Indicted Doc In Kickback Case Seeks CMS Billing Privileges.” Law360. (November 2, 2021). Web.

“Two Scranton area doctors charged in genetic testing bribery and kickback scheme.” PA Homepage. (July 17, 2020). Web.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620 or Toll-Free: (888) 331-6620.

“The Health Law Firm” is a registered fictitious business name of and a registered service mark of The Health Law Firm, P.A., a Florida professional service corporation, since 1999.
Copyright © 2022 The Health Law Firm. All rights reserved.

Florida Surgeon, Device Company Owner Arrested For Paying Bribes, Kickbacks

By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

On September 7, 2021, federal prosecutors announced the arrest of a Florida surgeon and owner of device company SpineFrontier Inc on charges of bribing surgeons to use products by paying sham consulting fees.

Accused in an indictment in Boston federal court for violating the federal Anti-Kickback Statute (AKS) and conspiracy to commit money laundering, is the company’s founder and CEO from Florida. Also charged in the indictment were the company’s chief financial officer from Massachusetts and the device company itself. The charges of AKS violations carry a maximum prison sentence of 10 years, while the money laundering conspiracy charge carries a maximum sentence of 20 years.

Click here to view the indictment in full.

Alleged Bribes & Kickbacks.

The allegations are that from March 2013 through December 2018, the defendants entered into consulting contracts in which they allegedly agreed to pay surgeons between $250 and $1,000 per hour for consulting work. However, prosecutors claim that the surgeons paid did little consulting work, and the payments only served as bribes to use their company’s products. During that time, surgeons accepted between $32,625 and $978,000 in improper payments, according to the indictment.

Department of Justice Civil Lawsuit For ‘Sham’ Consulting Fees.

In March 2020, the DOJ filed a civil lawsuit against SpineFrontier, accusing the company of illegally funneling more than $8 million to nearly three dozen surgeons. The complaint alleges that the defendants created a separate company which was used as an intermediary to funnel illicit payments to surgeons. Additionally, the indictment lists seven surgeons who have allegedly received bribes totaling $2,747,463 to serve as “sham consultants.” Read the complaint in full here to learn more.

In Summary.

The Anti-Kickback Statute (AKS) prohibits offering, paying, soliciting, or receiving remuneration to induce referrals of items or services covered by Medicare, TRICARE, and other federally funded programs. It is intended to ensure that a physician’s medical judgment is not compromised by improper financial incentives. Conspiring to violate the kickback laws, can bring up to five years in prison while actually violating the kickback laws can result in a sentence of up to 10 years.

“Kickbacks paid to surgeons as sham medical consultants, as alleged in this case, cheat patients and taxpayers alike,” reportedly said Phillip Coyne, Special Agent in Ccharge of the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG). “Working with our law enforcement partners, we will continue to investigate kickback schemes that threaten the integrity of our federal health care system, no matter how those schemes are disguised.”

You can read the DOJ’s press release on the case here.

Physicians Beware of Such Schemes.

Physicians should beware of any contract, plan or offer which offers them money for little or no work at all. They should also be aware of plans in which they are “given” ownership interest in or made officers in companies and businesses without their having to buy into them. Such schemes are often used by unscrupulous non-physicians to sucker in physicians so that they can be used to perpetrate criminal enterprises. In may cases, the scheme is to defraud Medicare or another health insurer. Often older or retired physicians seeking to supplement their income fail prey to such schemes. Often the purpose is just to obtain the physician’s personal identification number or DEA number to order false prescriptions and diagnostic tests or to carry out other fraudulent billing schemes. Physicians should always remember two old adages: “Nothing is free” and “If it seems to good to be true, it isn’t.”

Contact Health Law Attorneys Experienced with Health Care Fraud, False Claims Act Violations, and Anti-Kickback Statute Violations.

The attorneys of The Health Law Firm represent healthcare providers in cases of medical billing fraud, overbilling, Medicare audits, ZPIC audits and RAC audits, False Claims Act cases, and whistleblower/qui tam cases throughout Florida and across the United States. Our attorneys also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.

To contact The Health Law Firm, please call (407) 331-6620 or toll-free at (888) 331-6620 and visit our website at www.TheHealthLawFirm.com.

Sources:

Schulte, Fred. “Florida Spine Surgeon and Device Company Owner Charged in Kickback Scheme.” Kaiser Health News. (September 8, 2021). Web.

Pierson, Brendan. “SpineFrontier execs arrested, charged with kickback scheme.” Reuters. (September 7, 2021). Web.

“Florida Spine Surgeon And Device Company Owner Charged in Kickback Scheme.” Health News Florida. (September 8, 2021). Web.

HHS Announces Proposed Rules to Reform Stark Law and AKS Regulations

By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law
On October 9, 2019, the Centers for Medicare & Medicaid Services (CMS) and the Department of Health and Human Services (HHS) Office of Inspector General (OIG) issued two proposed rules to reform the federal Stark Law (dealing with prohibited self-referrals) and Anti-Kickback Statute (AKS) (addressing giving or receiving any thing of value in exchange for a patient referral) regulations.

The long-awaited proposed rules aim to “modernize and clarify” federal laws relevant to value-based and patient coordinated care programs. The proposals would ease the compliance burden for healthcare providers across the industry while maintaining strong safeguards to protect patients and programs from fraud and abuse.

The Proposed Stark Rule.

The proposed rule that would further implement and clarify the Stark Law, “Modernizing and Clarifying the Physician Self-Referral” would, if finalized, create new exceptions to the existing Stark Law for value-based arrangements, according to CMS. These exceptions would apply broadly to care provided to all patients, not just Medicare beneficiaries, CMS said. The proposed rule also includes additional clarifications and guidance on key statutory terms and other technical compliance requirements.

For more info, click here to view the Stark proposed rule’s fact sheet issued by CMS.

The Proposed AKS Rule.

The proposed rule to further implement and clarify the AKS, “Revisions to the Safe Harbors Under the Anti-Kickback Statute and Civil Monetary Penalty Rules Regarding Beneficiary Inducements” would make several changes to the AKS and beneficiary inducement provisions of the Civil Monetary Penalties Law (CMP). These changes would include the addition of several new AKS safe harbors for certain remuneration exchanged between or among eligible participants.

The new AKS safe harbors include care coordination arrangements aimed at improving quality and outcomes; value-based arrangements with substantial downside financial risk; and value-based arrangements with full financial risk, according to OIG.

Click here to view the fact sheet issued by CMS to learn more about the proposed rule.

To view the press release issued by the HHS in full, click here.

Contact Health Law Attorneys Experienced in Handling Stark Law and Anti-Kickback Statute Compliance.

If you are involved in referring or providing DHS, your arrangements must be reviewed for compliance with Stark and other anti-fraud laws. Violations of these laws can carry severe financial and criminal penalties. One of the best ways to avoid these sanctions is to have your current or potential arrangement reviewed by an attorney who is experienced in these matters.

The Health Law Firm routinely advises healthcare providers on Stark compliance issues for practitioners and providers of all types of DHS. We can advise you on the legality of a particular arrangement and can assist with remedying any perceived compliance issues. Our attorneys also represent providers in cases of medical billing fraud, overbilling, Medicare audits, ZPIC audits and RAC audits, False Claims Act cases, and whistleblower/qui tam cases throughout Florida and across the United States.

They also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.

To contact The Health Law Firm, please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.

Sources:

Kearbey, Amy. “CMS Publishes Proposed Amendments To Stark Law Advisory Opinion Regulations.” The National Law Review. (October 9, 2019). Web.

HHS Press Office. “HHS Proposes Stark Law and Anti-Kickback Statute Reforms to Support Value-Based and Coordinated Care.” HHS.gov, U.S. Department of Health & Human Services. (October 9, 2019). Web.

“CMS, OIG Release Long-Awaited Stark, AKS Proposed Rules.”AHLA. (October 9, 2019). Web.

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Florida Pharmacist Gets More Than Six Years in Prison For Role in Compounding Fraud Scheme

By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

On November 29, 2018, a Florida pharmacist was sentenced to six and a half years in prison and ordered to pay $3.4 million, for her role in a scheme to defraud the government. Marjorie Robinson pled guilty one count of conspiracy to commit health care fraud for submitting fraudulent claims to Tricare, Medicare and private insurance programs for compounded creams that were not necessary.

The Fraud Scheme.

According to the U.S. Department of Justice (DOJ), Robinson was one of three owners of ASC Pharmacy Inc., a now defunct compounding pharmacy in Miami. Under her direction, the pharmacy made compounded creams that were made to maximize reimbursement from government and private insurance programs, not for patients needs, according to the plea deal. Click here to read the press release from the DOJ.

The other owners were charged separately and have also pled guilty.

This isn’t the first time a Florida pharmacy has defrauded government programs like Tricare, click here to read one of my prior blogs on a similar case.

Health Care Fraud Should Not Be Taken Lightly.

We have been consulted by many individuals, both before and after criminal charges were brought for fraud or related offenses. In many cases, those subject to Medicare and Medicaid fraud audits and investigations refuse to acknowledge the seriousness of the matter. Some may even decide not to spend the money required for a highly experienced health attorney to defend them.

Click here to read one of my previous blog posts regarding Medicare and Medicaid audits.

The government is serious about combating health care fraud. It created a Medicare Fraud Strike Force in March of 2007, in an effort to further prevent and eliminate fraud and abuse of government health care programs. False claims are a growing problem in the program, costing the government billions of dollars each year. Accordingly, punishments for defrauding the system can be quite severe.

If you are accused of Medicare or Medicaid fraud, realize that you are in a fight for your life. Your liberty, property/possessions and profession are all at stake. Often it is possible to settle allegations of fraud by agreeing to pay civil monetary penalties and fines. If given such an opportunity, the provider should consider whether it is worth the risk of facing decades in prison. Be prepared to give up whatever you need to in order to avoid a conviction and preserve your liberty.

Don’t Wait Until It’s Too Late; Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now.

The attorneys of The Health Law Firm represent pharmacists and healthcare providers in Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S. They also defend pharmacists, physicians, pharmacies and medical groups in actions by Tricare, Medicare, Medicaid and private insurers to recoup overpayments, obtain civil fines and penalties and take other actions against them. They represent pharmacies and pharmacists in DEA actions and administrative (Order to Show Cause ) hearings, Medicare Fraud Control Unit (MFCU) investigations, and administrative and civil litigation, physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.

For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or (850) 439-1001.

Sources:

Bolado, Carolina. “Fla. Pharmacist Gets 6½ Years For Bogus Claims For Creams.” Law360. (November 29, 2018). Web.

“South Florida pharmacist sentenced to more than six years in prison for role in $3.4 million compounding pharmacy scheme.” MD Linx. (November 30, 2018). Web.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

KeyWords: Legal representation for pharmacists, pharmacy lawyer, legal representation for pharmacies, pharmacists lawyer, legal representation for healthcare fraud, health care fraud representation, healthcare fraud defense lawyer, legal representation for submitting false claims to the government, False Claims Act defense attorney, FCA legal counsel, FCA defense lawyer, Anti-Kickback Statute (AKS) defense attorney, FCA representation, legal representation for allegations of violating Anti-Kickback Statute, AKS representation, TRICARE false claims legal defense attorney, TRICARE physician representation, legal representation violating False Claims Act, pharmaceutical fraud lawyer, compounding pharmacy attorney, fraudulent practices of pharmaceutical companies, Medicare audit defense attorney, ZPIC audit defense lawyer, RAC audit defense legal counsel, pharmacy Tricare audit defense attorney, Medicare pharmacy defense lawyer, Medicaid audit of pharmacy defense counsel, pharmacy defense attorney for overpayment demand, pharmacy civil fine defense attorney, pharmacy DEA defense attorney, pharmacy Order to Show Cause (OTSC) defense lawyer, Medicare Fraud Control Unit (MFCU) investigation defense legal counsel, pharmacy administrative and civil litigation attorney, health care fraud defense legal representation, TRICARE fraud attorney, health law defense attorney, health care fraud defense attorney, The Health Law Firm, representation for health care fraud investigations, compounding pharmacy lawyer, prescription reimbursement representation, pharmacy defense attorney, pharmacist defense lawter, representation for pharmacies, representation for pharmacists, legal representation for health care facilities, representation for health care professionals, legal defense of TRICARE providers, U.S. Department of Justice (DOJ) investigation representation, DOJ defense attorney, representation for DOJ matters, attorney reviews of The Health Law Firm, The Health Law Firm attorney reviews

Two Nursing Home Co-Conspirators Sentenced in $19 Million Fraud Kickback Scheme

By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

On July 9, 2018, two co-conspirators in a $19.4 million healthcare fraud scheme involving a nursing home chain, American Senior Communities, were sentenced in Indiana federal court. Both pled guilty to various conspiracy and money laundering charges.

The Multi-Million Dollar Scheme.

Prosecutors allege that the men reached side deals with vendors who handled things like nurse call systems, food and medical supplies for the nursing home chain. According to the U.S. Department of Justice (DOJ), the kickback scheme generated nearly $19.4 million that the men spent on vacation homes, private planes, golf trips, Rolex watches, gold bullion and casino chips. Both were charged in 2016, along with two others for their roles in the same scheme. Read more about their involvement here.

The Sentencing.

The DOJ said Steven Ganote received a five-year sentence with two years of supervised release and was ordered to pay $7 million in restitution. Additionally, Joshua Burkhart was handed a four-month sentence with two years of supervised release and ordered to pay $420,000 in restitution. Each of the men is charged with one count of conspiracy to commit mail, wire and health care fraud, money laundering and conspiracy to violate the Anti-Kickback Statute (AKS).

To learn more about these types of illegal kickback schemes, click here to read one of my prior blogs on health care fraud.

Don’t Wait Until It’s Too Late; Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues, Fraudulent Billing and Overbilling Now.

The attorneys of The Health Law Firm represent healthcare providers in cases of medical billing fraud, overbilling, Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S. They also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.

For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or (850) 439-1001.

Sources:

Fowler, Haylay. “Nursing Home Schemer Sentenced In $19M Kickback Scheme.” Law360. (July 9, 2018). Web.

Kass, Dani. “Ex-Nursing Home Execs Indicted In $16M Kickback Scheme.” Law360. (October 12, 2016). Web.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

KeyWords: Medical billing fraud, fraudulent billing representation, fraudulent billing attorney, representation for overbilling, representation for submitting false claims, False Claims Act (FCA) violations, representation for submitting false claims, false claims lawyer, FCA defense attorney, Anti-Kickback Statute(AKS) violations, AKS representation, AKS attorney, representation for fraudulent reimbursement, representation for illegal kickback scheme illegal kickback scheme attorney, legal representation for health care professionals, health fraud defense lawyer, health law defense attorney, health law, The Health Law Firm

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
Copyright © 2018 The Health Law Firm. All rights reserved.

Florida Pharmacy Owner to Serve 15 Years in Prison for $100 Million Billing Fraud Scheme

By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

On April 26, 2018, the owner of several Florida pharmacies was sentenced to 15 years in prison and ordered to give up $54.5 million in restitution. Nicholas A. Borgesano Jr., owner of A to Z Pharmacies, pled guilty to his role in a $100 million scheme involving bogus insurance reimbursements for prescription drugs.

He pled guilty in November to charges of conspiracy to commit health care fraud and conspiracy to engage in monetary transactions in property derived from specified unlawful activity, according to the order. Click here to read more.

Health Care Billing Fraud Schemes.

According to prosecutors, Borgesano was at the center of an alleged scheme in which the pharmacy owner used his six stores to peddle prescription compound medications. He would then submit fraudulent reimbursement claims to Medicare, Tricare and private insurance companies.

Borgesano and his co-conspirators are accused of manipulating billing codes in the reimbursement claims and submit claims for pharmaceutical ingredients they didn’t even have. Additionally, he used one of his pharmacies in Florida as the hub of operations and paid his co-conspirators through shell companies, checks and the purchase of assets, prosecutors said.

From the pharmacy owner and his group of conspirators, the U.S. Department of Justice (DOJ) has seized $7.6 million worth of property, including several luxury vehicles and a 50-foot racing boat, the DOJ said. To read more about the co-conspirators, click here to read the press release issued by the DOJ.

To read the judgement in full click here.

The expensive prescription medications and creams involved in this case have been targeted by prosecutors in a handful of other Florida suits alleging Medicare and Tricare fraud by pharmacy owners and others. Click here to read one of my prior blogs involving a similar case.

Contact Health Law Attorneys Experienced in Representing Pharmacies and Pharmacists.

The Health Law Firm represents pharmacists and pharmacies in DEA, DOH and FDA investigations, qui tam and whistleblower cases, regulatory matters, licensing issues, litigation, administrative hearings, inspections and audits. The firm’s attorneys include those who are board certified by The Florida Bar in Health Law as well as licensed health professionals who are also attorneys.

To contact The Health Law Firm please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.

Sources:

Greene, Kat. “Pharmacy Owner Gets 15 Years For Role In $100M Scheme.” Law360. (April 27, 2018). Web.

Manning, Margie. “New Port Richey pharmacy owner sentenced in $100 million fraud scheme.” Tampa Bay Business Journal. (April 26, 2018). Web.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

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