Department of Justice (DOJ) | The Health Law Firm Blog

Hospitals Allegedly Enforcing Questionable Practices to Increase Bottom Line

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

Doctors and hospitals around the country seem to be butting heads. In the past month, an article in The New York Times and a segment on the television “magazine” show 60 Minutes shed light on some questionable practices being enforced by hospitals on physicians working for them.

I previously wrote a blog on this structural shift in the practice of medicine. Click here to read that blog.

The effects of this trend are examined in these two news stories. Doctors and former employees from a number of hospitals around the country were interviewed and all seem to be dealing with the same issues. The biggest concerns addressed were: pressure to order unnecessary tests, admitting patients to fill hospital quotas and drive hospital profits, and the feeling of being controlled by hospital executives and administrators instead of practicing effective medicine.

Doctors Allegedly Pressured to Fill Emergency Room Beds to Increase Profits.

On December 2, 2012, 60 Minutes aired an investigative segment on one of the largest for-profit hospital chains in the country. Former employees and physicians alleged this hospital system thrived by buying urban-area hospitals and turning them into profit centers by filing empty beds from emergency rooms. A former emergency medicine doctor stated that the hospital in which he worked required an admission rate of twenty percent (20%) for patients seen in the ER and fifty percent (50%) for patients who were 65 years old and older (most of whom are Medicare patients) seen in the ER.

A former hospital system employee interviewed by 60 Minutes claimed he was in charge of auditing the hospital chain in question. He stated that he was convinced that doctors were under an extraordinary amount of pressure to fill hospital beds. He stated that he personally audited hospitals in Texas, Florida and Oklahoma, and concluded there were hundreds of thousands of dollars submitted to Medicare and Medicaid for hospital stays that did not meet standards for reimbursement, including medical necessity.

Doctors interviewed for The New York Times article had similar stories. They stated in interviews that hospital administrators created quotas for how many patients should be admitted, because more admissions allegedly meant more money. Doctors who met or exceeded quotas were rewarded with increased compensation, while doctors who did not felt in danger of losing their jobs.

Click here to read the entire New York times article.

Consequences of Ordering Unnecessary Tests.

The New York Times article looked at a number of lawsuits filed by former employees who allege the hospitals they worked for compensated doctors for ordering more tests than necessary.

The Department of Justice (DOJ) recently settled with a hospital group in Joplin, Missouri. According to the DOJ press release, the hospital system had to pay more than $9.3 million for rewarding doctors partly based on how many tests they ordered. This is in direct violation of the Stark Law and the False Claims Act.

Click here to read the entire press release from the DOJ.

I recently wrote an article for Medical Economics on the legal ramifications of ordering unnecessary tests. To read that article, click here.

If you want to know more on the Stark Law, click here.

Doctors Feel Controlled By Hospital Executives.

Doctors also stated they felt controlled by hospital executives. This was due, in part, to a corporate wide computer software system that was customized to automatically order an extensive battery of tests, some unnecessary, as soon as a patient walked into the hospital. It’s also stated that the software would prompt a physician to reconsider when he or she decided to send an emergency room patient home.

Most doctors interviewed were upset that the program also generated reports that evaluated each doctor’s performance and productivity.

To watch the segment from 60 Minutes, click here.

Hospitals Say They are Embracing the New Model of Health Care.

The hospital system in question by 60 Minutes maintains that these allegations are not correct. The executive vice president said that as a whole admission rates haven’t changed in four years and are near or below industry averages. The hospital systems believe that by consolidating they are embracing the new model of health care and state patient care comes first.

Contact Health Law Attorneys Experienced in Representing Health Care Professionals and Providers.

At the Health Law Firm we provide legal services for all health care providers and professionals. This includes physicians, nurses, dentists, psychologists, psychiatrists, mental health counselors, Durable Medical Equipment suppliers, medical students and interns, hospitals, ambulatory surgical centers, pain management clinics, nursing homes, and any other health care provider. We represent facilities, individuals, groups and institutions in contracts, sales, mergers and acquisitions.

The services we provide include reviewing and negotiating contracts, business transactions, professional license defense, representation in investigations, credential defense, representation in peer review and clinical privileges hearings, Medicare and Medicaid audits, commercial litigation, and administrative hearings.

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

Comments?

Do you think there are constant battles between doctors and hospitals? As a health professional, have you experienced the pressure to admit patients, order unnecessary tests or refer a patient inside your network? Please leave any thoughtful comments below.

Sources:

Creswell, Julie and Abelson, Reed. “A Hospital War Reflects a Bind of Doctors in the U.S.” The New York Times. (November 30, 2012). From: http://www.nytimes.com/2012/12/01/business/a-hospital-war-reflects-a-tightening-bind-for-doctors-nationwide.html?pagewanted=all

Kroft, Steve. “Hospitals: The Cost of Admission.” 60 Minutes. (December 2, 2012). From: http://www.cbsnews.com/video/watch/?id=50136261n

Department of Justice. “Missouri Hospital System Agrees to Pay $9.3 Million to Resolve False Claims Act and Stark Law Violations.” DOJ. (November 5, 2012). From: http://www.justice.gov/printf/PrintOut3.jsp

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.

“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.

By The Health Law Firm|2024-03-14T10:00:42-04:00June 1, 2018|Categories: Health Care Industry, The Health Law Firm Blog|Tags: business transactions, closing attorney, contract attorney, contract lawyer, Department of Justice (DOJ), false claims act, Florida health care attorney, Florida health care lawyer, hospital acquisitions, Medicaid fraud, medical groups, Medicare fraud, merger legal counsel, overbilling, physician contract attorney, physician contract lawyer, private practice mergers, qui tam, reviewing and negotiating contracts, sale of practice, stark law, unnecessary tests, whistleblower|Comments Off

Hawaii Hospital to Pay More Than $451,000 to Resolve Whistleblower/Qui Tam Allegation of Improper Claims

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

Wahiawa General Hospital in Honolulu, Hawaii, agreed to pay $451,428 to settle two lawsuits alleging that the hospital improperly billed Medicare, Medicaid and Tricare. The settlement stemmed from a civil whistleblower/qui tam lawsuit. The lawsuit was filed by a doctor who allegedly worked at an outpatient clinic operated by Wahiawa General Hospital, according to the Department of Justice (DOJ). Wahiawa General Hospital signed the settlement agreement on August 29, 2013.

To read the press release from the DOJ, click here.

Whistleblower Receives Money in Settlement and Attorneys’ Fees Paid by Hospital.

According to the DOJ, the federal and state governments alleged that Wahiawa General Hospital wrongfully submitted claims to Medicare, Medicaid and Tricare from April 2008 through March 2011. The investigation was initiated after a doctor alleged the hospital submitted bills for services provided by resident doctors without the level of supervision required by law.

On top of the more than $451,000 settlement, Wahiawa General Hospital agreed to pay $75,000 in attorneys’ fees and costs to the attorneys who represented the doctor. The doctor will also receive more than $84,600 as part of the settlement, under the False Claims Act. To learn more on whistleblower/qui tam cases, read our two-part blog. Click here for part one, and click here for part two.

Most Qui Tams Filed by Doctors, Nurses and Employees.

From our review of whistleblower/qui tam cases that have been unsealed by the government, it appears most of these are filed by physicians, nurses or hospital staff employees who have some knowledge of false billing or inappropriate coding taking place. Normally the government will want to see some actual documentation of the claims submitted by the hospital or other institution. Usually physicians, nurses or staff employees have access to such documentation. Whistleblowers are urged to come forward as soon as possible. In many circumstances, documentation that shows the fraud “disappears” or cannot be located once it is known that a company is under investigation.

Contact Health Law Attorneys Experienced with Qui Tam or Whistleblower Cases.

Attorneys with The Health Law Firm also represent health care professionals and health facilities in qui tam or whistleblower cases both in defending such claims and in bringing such claims. We have developed relationships with recognized experts in health care accounting, health care financing, utilization review, medical review, filling, coding, and other services that assist us in such matters. We have represented doctors, nurses and others as relators in bringing qui tam or whistleblower cases, as well.

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

Comments?

Individuals working in the health care industry often become aware of questionable activities. Often they are even asked to participate in it. In many cases the activity may amount to fraud on the government. Has this ever happened to you? Please leave any thoughtful comments below.

Sources:

Associated Press. “Wahiawa General Hospital to Pay $450K Settlement.” Star Advertiser. (August 30, 2013). From: http://www.staradvertiser.com/news/breaking/221856781.html

Department of Justice. “Community Hospital Pays $451,428 to Resolve Allegation of Improper Claims.” Department of Justice. (August 30, 2013). From: http://www.justice.gov/usao/hi/news/1308wgh.html

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.

“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 © 1996-2012 The Health Law Firm. All rights reserved.

By The Health Law Firm|2024-03-14T10:00:51-04:00June 1, 2018|Categories: False Claims Act, Medicare Fraud, The Health Law Firm Blog, Whistleblower|Tags: defense attorney, defense lawyer, Department of Justice (DOJ), doctor, false billing, false claims, false claims act, Hawaii health care fraud, health care fraud, improper claims, legal representation, medicaid, medicaid audit, Medicaid false claims, medicare, medicare audit, Medicare false claims, Medicare fraud, physician, qui tam, qui tam lawsuits, qui tam lawyer, settlement agreement, the health law firm, TRICARE, Tricare false claims, Tricare fraud, Wahiawa General Hospital, whistleblower, whistleblower attorney, whistleblower lawyer, whistleblower protection|Comments Off

Specialty Pharmacy Agrees to Pay A $11.4 Million Settlement in Whistleblower Case

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

The Department of Justice (DOJ) announced on December 27, 2012, that a specialty pharmacy, based in San Diego, California, has agreed to pay a $11.4 million settlement. That payment is to resolve allegations that the company used kickbacks to persuade doctors to write prescription for its products. The allegations came from a whistleblower lawsuit filed by a former employee.

Click here to read the press release from the DOJ.

Specialty Pharmacy Allegedly Used Expensive Kickbacks to Bribe Doctors.

An article in Modern Healthcare states that the specialty pharmacy allegedly used tickets to sporting events, concerts, plays, spa outings, golf games and ski trips to bribe doctors to write prescriptions for its products. The company also had representatives schedule paid “preceptorships,” where the reps would follow doctors in their offices in an attempt to increase prescriptions written for their products.

To read the Modern Healthcare article, click here.

Specialty Pharmacy Will Pay More Than $11 Million.

The specialty pharmacy company agreed to a forfeiture of $1.4 million to resolve the anti-kickback statue allegations. It will also pay $9.9 million to resolve false claims allegations, according to the DOJ. Representatives with the DOJ said that by entering the deferred prosecution agreement the company was able to avoid criminal and civil liability for the kickback and false claims violations.

Whistleblower Gets $1.7 Million Reward.

According to the DOJ, the settlement resolves a False Claims Act lawsuit that was filed by a former sales representative for the specialty pharmacy. As part of the resolution, that whistleblower will receive $1.7 million.

Whistleblowers stand to gain substantial amounts, sometimes as much as thirty percent (30%), of the amount the government recovers under the False Claims Act (31 U.S.C. Sect. 3730). Such awards encourage employees and contractors to come forward and report fraud. You can learn more on the False Claims Act on the DOJ website.

Contact Health Law Attorneys Experienced with Qui Tam or Whistleblower Cases.

Attorneys with The Health Law Firm also represent health care professionals and health facilities in qui tam or whistleblower cases. We have developed relationships with recognized experts in health care accounting, health care financing, utilization review, medical review, filling, coding, and other services that assist us in such matters.

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

Comments?

What do you think of the settlement agreement? As a health professional are you tempted with kickbacks? Please leave any thoughtful comments below.

Sources:

Department of Justice. “Victory Pharma Inc. of San Diego Pays $11.4 Million to Resolve Kickback Allegations in Connection with Promotion of Its Drugs.” Department of Justice. (December 27, 2012). From: http://www.justice.gov/opa/pr/2012/December/12-civ-1547.html

Kutscher, Beth. “$11.4 Million Settlement in Pharma Kickback Case.” Modern Healthcare. (December 27, 2012). From: http://www.modernhealthcare.com/article/20121227/NEWS/312279957/

About the Authors: Lance O. Leider is an attorney with 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, Altamonte Springs, Florida 32714, Phone: (407) 331-6620.

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.

“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.

By The Health Law Firm|2024-03-14T10:00:43-04:00June 1, 2018|Categories: Pharmacy, The Health Law Firm Blog, Whistleblower|Tags: Anti-kickback statue, Department of Justice (DOJ), false claims act, health care fraud, health care scheme, kickback scheme, legal representation, pharmaceutical company, qui tam suits, specialty pharmaceutical company, whistleblower, whistleblower attorney, whistleblower lawyers, whistleblower protection|Comments Off

Miami “Rock Doc” Arrested on Medicare Fraud Charges

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

An osteopathic physician in Miami, Florida, dubbed the “Rock Doc,” was arrested on September 30, 2013. He is charged with twelve (12) counts of health care fraud, according to the Department of Justice (DOJ). The “Rock Doc” is accused of falsely billing the Medicare program for physical therapy procedures, such as massages and electrical stimulation, which were not necessary. If convicted the doctor faces up to ten (10) years in prison and a $250,000 fine.

Click here to read the press release from the DOJ.

In 2010, this osteopathic physician was the feature of a Wall Street Journal article called “Confidentiality Cloaks Medicare Abuse.” The article looked into the billing practices of the “Rock Doc” and many other doctors performing physical therapy and reaping the reimbursements from Medicare.

The physician’s nickname, “Rock Doc,” stems from his appearance of spiked, punk-styled hair, along with accessories of chains, bangles and leather bracelets.

Indictment Accuses Doctor of Spending Reimbursements on Himself.

According to the indictment, the “Rock Doc” is accused of falsely and fraudulently representing that his physical therapy treatments and services were medically necessary and had been provided to Medicare beneficiaries between December 2007 and August 2009. The indictment also alleges that he used the Medicare payments on himself or others.

To read the indictment against the osteopathic “Rock Doc” physician, click here.

Medicare regulations require that physical therapists billing under a physician must have completed an accredited physical-therapy education program. However, in the Wall Street Journal article, the “Rock Doc” said that he trained his “office girls” to do the work because hiring a physical therapist was too expensive.

Wall Street Journal Article Highlighted Physician’s High Medicare Reimbursements.

According to the Wall Street Journal article released in 2010, the “Rock Doc” admitted to receiving more than $2.6 million from Medicare between 2007 and 2009. His gross payments were allegedly more than 24 times the Medicare income of the average family doctor.

In 2009, Medicare administrators caught onto the doctor’s billing activity and began scrutinizing his bills. That increased oversight led him to sell his business.

According to the Miami Herald, the doctor was currently working at a hospital in Larkin County, Florida, when he was arrested.

To read the Miami Herald article, click here.

Fraud Charges Must Be Taken Seriously.

We have been consulted by many individuals, both before and after criminal convictions for fraud or related offenses. There are many times audit investigators must make a judgment on whether overcharges are simply an honest mistake or fraud. In many instances, we are convinced that the person is actually not guilty of fraud. However, in many cases those subject to Medicaid or Medicare fraud audits and investigations refuse to acknowledge the seriousness of the matter or they decide not to spend the money required for a top quality attorney to defend them.

If you are accused of Medicare or Medicaid fraud, realize that you are in the fight of your life. You need to sell everything you own, borrow everything you can and hire the absolute best criminal defense attorney available who has experience in defending such cases to represent you.

If you win and are acquitted, at least you still have a professional license and can start over. However, if you lose, you will most probably be in prison for years. You will lose your license. You will be excluded from Medicare. You will be a convicted felon. You will have nothing and will have no way of starting over successfully. Do not delude yourself. This is extremely serious. Be prepared to give up whatever you have if you can avoid a conviction.

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 healthcare providers in 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.

Comments?

Do you think that being the subject of the Wall Street Journal article back in 2010, the “Rock Doc” basically alerted the government to his fraudulent billing practices? Please leave any thoughtful comments below.

Sources:

Weaver, Jay. “Miami Beach’s ‘Rock Doc’ Busted on Medicare Fraud Charges.” Miami Herald. (September 30, 2013). From: http://www.miamiherald.com/2013/09/30/3660611/miami-beachs-rock-doc-busted-on.html

Department of Justice. “Miami Physician Indicted in Medicare Fraud Scheme.” Department of Justice. (September 30, 2013). From: http://www.justice.gov/usao/fls/PressReleases/130930-01.html

United States of America vs. Christopher Gregory Wayne. Case Number 13-206912. Indictment. (September 30, 2013). From: http://www.thehealthlawfirm.com/uploads/RockDoc.Indictment.pdf

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.

“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 © 1996-2012 The Health Law Firm. All rights reserved.

By The Health Law Firm|2024-03-14T10:00:52-04:00June 1, 2018|Categories: Health Care Industry, Medicare, Medicare Audit, Medicare Fraud, The Health Law Firm Blog|Tags: defense attorney, defense lawyer, Department of Justice (DOJ), doctor, false claims, florida health attorney, Florida health lawyer, health care fraud, Health Care Fraud Prevention and Enforcement Action Team (HEAT), health care fraud scheme, health care kickbacks, health law The Health Law Firm, M.D., medically necessary services, medicare, medicare audit, Medicare beneficiaries, Medicare fraud, Medicare fraud scheme, Miami Medicare fraud, Miami Medicare scheme, osteopathic physician, physical therapy fraud, physical therapy services, physician|Comments Off

Ohio Hospital Settles Whistleblower Case to Resolve False Claims Act Allegations

By Lance O. Leider, J.D., Attorney, The Health Law Firm

A group of doctors accused of performing an unusually high number of heart procedures on patients at an Ohio hospital has settled a whistleblower lawsuit, according to the Department of Justice (DOJ). The settlement agreement covers accusations that the doctors and the hospital billed Medicare for unnecessary cardiac procedures from 2001 to 2006.

Click here to read the press release from the DOJ.

The Ohio hospital agreed to pay the U.S. government $3.9 million, and the physician group agreed to pay $541,870 to settle the accusations.

Former Hospital Manager Speaks Up.

In October of 2006, the hospital’s former manager of the catheterization lab filed a whistleblower complaint. In the lawsuit the former employee said doctors at the Ohio hospital would allegedly encourage nurses and other staff to falsify complaints of chest pain to justify angioplasties.

In the same year, The New York Times found that in Elyria, Ohio, which is where the hospital in question is located, Medicare patients received angioplasties at a rate that was nearly four times the national average. This story prompted insurers to question the doctors’ treatment methods. To read the entire article from the New York Times, click here.

Hospital Addresses Settlement in Blog Post.

The Ohio hospital paying the settlement posted a statement on its website stating the doctors who performed these procedures felt confident they were making the right decisions for their patients. It’s explained that the settlement is not an admission of wrongdoing, but a platform to move forward. You can read the entire statement from the hospital by clicking here.

Unnecessary Cardiac Procedures are Under the Microscope.

This settlement is just one example of the government going after cardiologists and hospitals for performing unnecessary and expensive procedures. In August 2012, we wrote a blog about the investigation into the cardiology services performed at Florida HCA hospitals. Click here to read that blog.

The Health Law Firm’s President and Managing Partner, George F. Indest III, wrote an article on the legal ramifications for performing unnecessary tests and procedures. You can read that article by clicking here.

Contact Health Law Attorneys Experienced with Qui Tam or Whistleblower Cases.

Attorneys with The Health Law Firm also represent health care professionals and health facilities in qui tam or whistleblower cases. We have developed relationships with recognized experts in health care accounting, health care financing, utilization review, medical review, filling, coding, and other services that assist us in such matters.

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

Comments?

What do you think about this settlement? Are cardiologists and hospitals being unfairly targeted? Please leave any thoughtful comments below.

Sources:

Abelson, Reed. “U.S. Settles Accusations That Doctors Overtreated.” New York Times. (January 4, 2013). From: http://www.nytimes.com/2013/01/05/business/us-settles-accusations-that-doctors-overtreated.html?_r=0

Department of Justice. “EMH Regional Medical Center and North Ohio Heart Center to pay $4.4 million to resolve False Claims Act Allegations.” Department of Justice. (January 4, 2013). From: http://www.justice.gov/usao/ohn/news/2013/04janemh.html

North Ohio Heart. “North Ohio Heart Reaches Settlement; Continues to Provide High-Quality Cardiac Care.” Ohio Medical Group. (January 4, 2013). From: http://blog.partnersforyourhealth.com/Blog/bid/93734/North-Ohio-Heart-Reaches-Settlement-Continues-to-Provide-High-Quality-Cardiac-Care
About the Author: Lance O. Leider is an attorney with 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, Altamonte Springs, Florida 32714, Phone: (407) 331-6620.

“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.

By The Health Law Firm|2024-03-14T10:00:43-04:00June 1, 2018|Categories: Health Care Industry, In the News, The Health Law Firm Blog, Whistleblower|Tags: Department of Justice (DOJ), false billing, false claims, false claims act, legal representation, medicare, medicare audit, Medicare false claims, Medicare fraud, qui taim, qui tam suits, unnecessary procedures, whistleblower, whistleblower attorney, whistleblower lawyers, whistleblower protection|Comments Off

Miami Medical Clinic Owner Pleads Guilty to $20 Million in Medicare Fraud

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

The owner of a Miami-based medical clinic pleaded guilty on January 8, 2014, for her involvement in several health care fraud schemes that allegedly cost the Medicare program around $20 million. The schemes allegedly involved fraudulent billing for home health care services and therapy prescriptions to patients that may not have required them, according to the Associated Press. The owner operated Merfi Corp., a medical clinic that employed physicians, physician assistants and other medical professionals authorized to dispense prescriptions for home health care services.

Click here to read the Associated Press article.

The medical clinic owner faces up to 10 years in prison and is scheduled to be sentenced in March 2014.

Medicare Fraud Scheme Involved Kickbacks and Brides.

According to an article on Home Health Care News, through Merfi, the owner and her co-conspirators were allegedly given kickbacks and brides for providing fraudulent home health and therapy prescriptions and other medical documentation to owners and operators of other home health agencies and patient recruiters. The fraudulent documents were then used to bill Medicare.

To read the entire article from Home Health Care News, click here.

Case Investigated by Medicare Fraud Strike Task Force.

This case was investigated by the Medicare Fraud Strike Task Force. This task force has charged more than 1,700 defendants who have collectively billed the Medicare program for more than $5.5 billion since the agency’s inception in March 2007. To learn more about the Medicare Fraud Strike Force’s anti-fraud efforts, click here to read a previous blog.

What You Need to Know about Medicare and Medicaid Audits.

I previously wrote a two-part blog on the increased number of Medicare and Medicaid audits being initiated against health professionals who treat home health care, assisted living facility (ALF) and skilled nursing facility (SNF) residents. This area of medical practice has been identified as one fraught with fraud and abuse. To learn more on the areas being targeted and how to respond to different types of audits click here for the first blog, and click here for the second.

Physicians, Nurse Practitioners and Physician Assistants Must Check Out Their Employers.

I have previously written blogs warning licensed health practitioners about illegal health care clinics. Often the individuals involved in fraudulent acts will use an unlicensed health clinic as a vehicle to process false claims. Licensed health professionals should jealously protect their Medicare and Medicaid provider numbers and make sure that they do not allow their name or numbers to be used in false billing activities. Check out any company or corporation that employs you to be sure it is properly licensed, as necessary. To read a previous blog I wrote on unlicensed health clinics, click here.

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 healthcare providers in 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.

Comments?

Do you think similar schemes are fairly common? Do you think we will see more news stories like this with the increased anti-fraud efforts of the Medicare Fraud Strike Task Force? Please leave any thoughtful comments below.

Sources:

Associated Press. “South Florida Woman Guilty in $20M Medicare Fraud Scheme.” Miami Herald. (January 8, 2014.) From: http://www.miamiherald.com/2014/01/08/3858269/fla-woman-guilty-in-20m-medicare.html

Oliva, Jason. “Miami Clinic Owner Pleads Guilty to $20 Million Home Health Fraud.” Home Health Care News. (January 8, 2013). From: http://bit.ly/1h87Xv4

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.

“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 © 1996-2012 The Health Law Firm. All rights reserved.

By The Health Law Firm|2024-03-14T10:00:54-04:00June 1, 2018|Categories: Medicare, Medicare Audit, The Health Law Firm Blog|Tags: defense attorney, defense lawyer, Department of Justice (DOJ), false claims, Florida health care attorney, Florida health care lawyer, health care fraud, Health Care Fraud Prevention and Enforcement Action Team (HEAT), health care fraud scheme, health care kickbacks, health law, home health care company, kickbacks, medical clinic, medicare, medicare audit, Medicare beneficiaries, Medicare fraud, Medicare fraud scheme, Medicare Fraud Strike Task Force, patient recruiter, the health law firm|Comments Off

Medicare Put the Hospice Industry Under the Microscope

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

It’s no surprise to anyone that Medicare is cracking down on hospices around the country. According to a report by the Office of Inspector General (OIG), eighty-two percent (82%) of hospices’ claims did not meet Medicare coverage requirements. That is why Medicare is investigating the industry as a whole. Specific details on what Medicare is looking for can be found in the 2013 OIG Work Plan. Click here to read the 2013 OIG Work Plan.

So far, Medicare has kept true to its word. During the week of January 7, 2013, the federal government announced it is suing a Central Florida hospice for Medicare fraud, according to the Orlando Sentinel. (Click here to read the Orlando Sentinel article.) Also, one of the nation’s largest and most respected hospices located in San Diego, California, is in the middle of a federal audit, according to a Kaiser Health News article. (Click here to read the Kaiser Health News article.) These are just a few examples of what hospices around the country are dealing with.

Central Florida Hospice Dealing with Qui Tam or Whistleblower Case.

The federal qui tam (whistleblower) lawsuit against the Central Florida hospice was reportedly filed by the hospice’s former vice president of finance in September 2011. The Department of Justice (DOJ) joined the whistleblower lawsuit in September of 2012.

The federal lawsuit alleges the hospice CEO ordered employees to admit patients without properly determining whether they were terminally ill, as required by Medicare. Staff was also apparently told to find ways to “edit” patients’ medical files so that the billing appeared legitimate. To learn more on this case, click here to read a blog I wrote on the hospice when the government joined the lawsuit. Click here to read the entire whistleblower complaint.

San Diego Hospice Cuts More Than Just Patients After Medicare Audit.

In 2010, federal officials audited a large hospice located in San Diego, California. Medicare is still investigating the hospice’s 2009-2010 admissions. Since the audit, the hospice has had to drop around 400 patients, due to their ineligibility for hospice care. Cutting patients meant a decrease in profits, which subsequently meant the hospice had to let 260 employees go and close a 24-bed hospital, according to Kaiser Health News.

Hospices Under Scrutiny.

According to the Kaiser Health News article, the hospice industry is booming. In 2011, it’s estimated hospices served 1.65 million people in the U.S., which is about forty-five percent (45%) of all those who died that year. Medicare paid for the hospice benefits of eighty-four percent (84%) of those patients.

Medicare is concerned with the amount of people hospices admit. Hospices normally treat patients with fewer than six months to live. If a patient recovers, Medicare expects the patient to leave the program. Patients may stay in hospice care only if they are re-certified as still likely to die within six months by a physician. It’s thought that enrollment bonuses to employees and kickbacks to nursing homes that refer patients are big factors as to why hospices accept ineligible patients.

Medicare Trying to Keep Up with Fraud and Abuse in Hospice Industry.

Currently, the Centers for Medicare and Medicaid Services (CMS) is focused on safeguarding tax payers dollars from fraud. I have recently seen a number of audits initiated against health professionals who treat assisted living facility (ALF), hospice and skilled nursing facility (SNF) residents. Most often these are audits by the Medicare Administrative Contractor (MAC), because these facilities have been identified as fraught with fraud and abuse. I wrote a two-part blog this topic. Click here for part one and here for part two.

If you are being audited, click here to read some tips we recommend in responding to a Medicare audit.

Contact Health Law Attorneys Experienced in Handling Medicaid and Medicare Audits.

The Health Law Firm’s attorneys routinely represent physicians, medical groups, clinics, pharmacies, nurses, durable medical equipment (DME) suppliers, home health agencies, nursing homes and other healthcare providers in Medicaid and Medicare investigations, audits and recovery actions.

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

What Do You Think?

What do you think about Medicare targeting hospices? Do you think it is necessary? Is the hospice business going to suffer because of these investigations? Please leave any thoughtful comment below.

Sources:

Santich, Kate. “Feds Sue Hospice of the Comforter for Medicare Fraud.” Orlando Sentinel. (January 14, 2013). From: http://www.orlandosentinel.com/news/local/breakingnews/os-feds-sue-hospice-of-the-comforter-20130114,0,7827264.story

U.S. ex rel. Stone v. Hospice of the Comforter, Inc., No. 6:11-cv-1498-ORL-22-AAB (M.D. Fla) United State District Court for the Middle District of Florida Orlando Division. (September 12, 2012), available at http://www.thehealthlawfirm.com/uploads/US%20v%20Hospice%20of%20the%20Comforter.pdf

Dotinga, Randy. “Slowly Dying Patients, Am Audit and A Hospice’s Undoing.” Kaiser Health News. (January 16, 2013). From: http://www.kaiserhealthnews.org/Stories/2013/January/16/san-diego-hospice.aspx

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.

“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.

Duke University Health System Pays $1 Million to Settle Allegations of False Claims in Whistleblower Lawsuit

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

On March 21, 2014, Duke University Health System in Raleigh, North Carolina, settled a whistleblower/qui tam lawsuit, according to the Department of Justice (DOJ). The lawsuit, filed in 2012, stated that the three-hospital academic medical center is alleged to have fraudulently inflated its Medicare bills by unbundling a number of cardiac services and billing for physician assistants’ (PAs) time illegally. Duke University Health System agreed to pay $1 million to resolve these allegations.

Click here to read the press release from the DOJ.

Duke University Health System Accused of Submitting False Claims to Federal Health Care Programs.

According to the complaint, the lawsuit was originally filed by a former health care bill coder and quality-control auditor for Duke’s revenue-cycle subsidiary, Duke Patient Revenue Management Organization. The former employee accused Duke University Health System of allegedly making false claims to Medicare, Medicaid and TRICARE by billing the government for services provided by PAs during coronary artery bypass surgeries when the PAs were acting as surgical assistants, which is not allowed. The whistleblower also alleged the medical center increased billing by unbundling claims when the unbundling was not appropriate. These unbundled claims were associated with cardiac and anesthesia services, according to the complaint.

To read the whistleblower’s complaint filed in December of 2012, click here.

According to the DOJ, the claims resolved by the settlement are allegations only, and there has been no determination of liability.

Whistleblowers Who Report Fraud and False Claims Against the Government Are Usually Employees.

Doctors, nurses or staff employees working for hospitals, nursing homes, medical groups, home health agencies or others, often become aware of questionable activities. They are sometimes even asked to participate in it. In many cases the activity may amount to health care fraud.

It does not matter who you are. You may even be actively involved in the wrongdoing. This does not disqualify you from reporting the false claims activity or receiving a reward for doing so. In order to encourage employees with knowledge of fraudulent activity to come forward, the government will usually not seek to prosecute or punish that person in any way.

Normally the government will want to see some actual documentation of the claims submitted by the hospital or other institution. Usually physicians, nurses or staff employees have access to such documentation. Whistleblowers are urged to come forward as soon as possible. In many circumstances, documentation that shows the fraud “disappears” or cannot be located once it is known that a company is under investigation.

Of course, the larger the amount of money the government has been defrauded the more likely it will be that the government will be interested in pursuing the case and the larger the reward the whistleblower will receive if there is a recovery.

To read more on whistleblower cases, read my previous blogs. Click here for part one, and click here for part two.

Contact Health Law Attorneys Experienced with Qui Tam or Whistleblower Cases.

Attorneys with The Health Law Firm also represent health care professionals and health facilities in qui tam or whistleblower cases both in defending such claims and in bringing such claims. We have developed relationships with recognized experts in health care accounting, health care financing, utilization review, medical review, filling, coding, and other services that assist us in such matters. We have represented doctors, nurses and others as relators in bringing qui tam or whistleblower cases, as well.

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

Comments?

What do you think of this settlement? Do you think whistleblower lawsuits are becoming more common? Please leave any thoughtful comments below.

Sources:

Carlson, Joe. “Duke Pays $1 Million to Settle Whistle-Blower Case.” Modern Healthcare. (March 25, 2014). From: http://bit.ly/1g3W7yw

Department of Justice. “Duke University Health System, Inc. Agrees to Pay $1 Million For Alleged False Claims Submitted to Federal Health Care Programs.” Department of Justice. (March 21, 2014). From: http://www.justice.gov/usao/nce/press/2014/2014-mar-21.html

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.

“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 © 1996-2014 The Health Law Firm. All rights reserved.

By The Health Law Firm|2024-03-14T10:00:56-04:00June 1, 2018|Categories: False Claims Act, The Health Law Firm Blog, Whistleblower|Tags: billing for bundled claims, defense attorney, defense lawyer, Department of Justice (DOJ), Duke University Health System, false claims act, FCA, Florida Medicare, fraud defense, fraud prevention, fraud schemes, government health programs, health care fraud, health law firm, legal representation, medicaid, medicare, Medicare billing, Medicare fraud, North Caroline health care fraud, PA, physician assistant, physician assistant billing, qui tam, qui tam attorney, qui tam lawsuit, qui tam lawyer, the health law firm, TRICARE, unbundling, whistleblower, whistleblower lawsuit, whistleblower lawyer, whistleblower protection|Comments Off

Phony Florida Physician Uses Silicone and Krazy Glue – Arrested Twice for Practicing Medicine Without a License

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

A South Florida man was arrested on February 6, 2013, for allegedly injecting people with silicone in a West Palm Beach motel room. He has been charged with practicing medicine without a license. According to the Sun Sentinel, this was the man’s second arrest within two months for the same crime.

Click here to read the entire article from the Sun Sentinel.

This “Krazy” Tale.

Police say this fake physician injected his customers with buttocks-enhancing silicone injections. He would then allegedly seal up the skin wounds with Krazy Glue. Victims said he would not wear gloves or protective clothing during the procedures. Each victim was charged $200 for each visit. This phony health professional was also arrested in January 2013, when two victims told investigators similar stories about his illegal injections.

In each case, the side effects in patients included severe infections, and the damage is thought to be permanent.

South Florida and Phony Health Professionals.

This is by no means the first report we’ve heard of phony health professionals in South Florida injecting people with toxic chemicals. Back in 2012, a number of people became sick and deformed after a Broward County, Florida, woman allegedly injected victims’ buttocks, hips and breasts with a combination of Fix-A-Flat tire sealant, cement, mineral oil and Super Glue. One of the victims died as a result of the procedure, according to the Daily Mail Reporter. The victims claimed the woman administering the injections presented herself as a medical professional and wore a nurse’s uniform.

Practicing Without a License Is a Crime.

Practicing medicine without a license is a crime. Additionally, so is helping someone practice medicine without a license. As a practitioner, you may be asked to supervise or join a practice. Remember that your license may be at stake with any wrongdoing by your subordinates. Before you join a practice or agree to supervise others, check first with the Department of Health (DOH) that the other providers are legitimate. You can verify a license for free on the DOH’s website.

Also, remember that a license to practice medicine in Venezuela, Cuba, or anywhere else, is just that: a license to practice in that country. It does not allow a person to practice medicine in the United States. A specific license from the State of Florida is required to practice in Florida, except for certain military and federal physicians. Always check the physician’s license.

More Stories on Fake Physicians and Other Phony and Fraudulent Professionals to Come.

In the near future on this blog we will include additional articles on fake doctors and health professionals, some old, some new.

To see a blog on a fake dentist in Miami, click here. You can also read the story of a fake plastic surgeon in New York by clicking here.

Contact Health Law Attorneys Experienced with Investigations of Health Professionals and Providers.

The attorneys of The Health Law Firm provide legal representation to physicians, nurses, nurse practitioners, CRNAs, dentists, pharmacists, psychologists and other health providers in Department of Health (DOH) investigations, Drug Enforcement Administration (DEA) investigations, FBI investigations, Medicare investigations, Medicaid investigations and other types of investigations of health professionals and providers.

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

What do you think of all of these news stories of phony health care professionals? Please leave any thoughtful comments below.

Sources:

Komedna, Ed. “‘Motel Surgeon’ Arrested Again for Silicone Injections, Deputies Say.” Sun Sentinel. (February 6, 2013). From: http://www.sun-sentinel.com/news/palm-beach/fl-butler-surgery-arrest-20130206,0,2237567.story

United Press International Inc. “Man Arrested Again for Buttocks Injections.” United Press International Inc. (February 6, 2013). From: http://www.upi.com/Top_News/US/2013/02/07/Arrest-for-illegal-silicone-injections/UPI-97251360271074/?spt=hs&or=tn

Daily Mail Reporter. “Toxic tush transgender nurse charged with manslaughter after patient DIES following ‘injection with rubber cement and tire sealant in backroom cosmetic surgery’.” (July 26, 2012). From: www.dailymail.co.uk/news/article-2179631/Toxic-tush-nurse-Oneal-Morris-charged-manslaughter-patient-DIES.html#axzz2KKi2pPmh

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.

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 © 1996-2012 The Health Law Firm. All rights reserved.

Kansas Cancer Treatment Center and Owner Pay $2.9 Million Settlement for Alleged False Claims Act Violations

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

A whistleblower or qui tam lawsuit against a cancer treatment facility in Kansas has been settled. On April 14, 2014, the Hope Cancer Institute and its owner agreed to pay $2.9 million to resolve allegations that they violated the False Claims Act by defrauding Medicare, Medicaid and the Federal Employee Health Benefits Program. According to the complaint, it is alleged that the cancer treatment facility submitted false claims for drugs and services that were not provided to beneficiaries.

Click here to read the entire whistleblower complaint filed in 2012.

The complaint identifies three former employees of Hope Cancer Institute as the plaintiffs or “relators” in this case.

Owner Allegedly Instructed Employees to Submit Inflated Claims and Altered Medical Records.

According to the Department of Justice (DOJ), between 2007 and 2011, the Hope Cancer Institute’s owner allegedly instructed employees to bill for a predetermined amount of cancer drugs at certain dosage levels. However patients were allegedly given lower dosages of these drugs. This resulted in the center submitting false claims to federal health care programs for drugs that were not actually provided to beneficiaries. The three plaintiffs also stated they watched the owner use a paper cutter and tape to alter medical records before faxing them to Medicare. The employees’ investigation allegedly turned up altered documents for 13 patients.

To read the entire press release from the DOJ, click here.

The claims made against the Hope Cancer Institute and its owner are allegations. There has been no determination of liability.

Most Qui Tam Claims Filed by Employees.

The plaintiffs in this case filed the lawsuit against their employer under the qui tam or whistleblower provision of the False Claims Act. This law encourages whistleblowers to file fraud claims on behalf of the government by giving them a share of whatever the government collects, usually 15 percent (15%) to twenty-five percent (25%). Under the law, the employees are also required to give the DOJ the evidence they have collected so the government can join the lawsuit.

From our review of qui tam cases that have been unsealed by the government, it appears most of these are filed by physicians, nurses or staff employees who have some knowledge of false billing or inappropriate coding taking place. Typically the government will want to see some actual documentation of the claims submitted by the hospital or other institution. Physicians, nurses or staff employees usually have access to such documentation. Whistleblowers are urged to come forward as soon as possible. In many circumstances, documentation showing fraud “disappears” or cannot be located once it is known that a company is under investigation.

To learn more on whistleblower cases, read our two-part blog. Click here for part one, and click here for part two.

Contact Health Law Attorneys Experienced with Qui Tam or Whistleblower Cases.

Attorneys with The Health Law Firm also represent health care professionals and health facilities in qui tam or whistleblower cases both in defending such claims and in bringing such claims. We have developed relationships with recognized experts in health care accounting, health care financing, utilization review, medical review, filling, coding, and other services that assist us in such matters. We have represented doctors, nurses and others as relators in bringing qui tam or whistleblower cases, as well.

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

Comments?

Individuals working in the health care industry often become aware of questionable activities. Often they are even asked to participate in it. In many cases the activity may amount to fraud on the government. Has this ever happened to you? Please leave any thoughtful comments below.

Sources:

Department of Justice. “Government Settles False Claims Act Allegations Against Kansas Cancer Treatment Facility and Its Owner.” Department of Justice. (April 14, 2014). From: http://www.justice.gov/opa/pr/2014/April/14-civ-378.html

United States of America ex rel., Krisha Turner, Crystal Dercher and Amanda Reynolds v. Hope Cancer Institute, Inc. Case Number 2:12-cv-02122-EFM-JPO. Complaint. (March 1, 2012).

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.

“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 © 1996-2014 The Health Law Firm. All rights reserved.

By The Health Law Firm|2024-03-14T10:00:56-04:00June 1, 2018|Categories: False Claims Act, Medicare, Medicare Audit, Medicare Fraud, Our Firm, qui tam, The Health Law Firm Blog, Whistleblower|Tags: defense attorney, defense lawyer, Department of Justice (DOJ), false claims act, FCA, Florida Medicare, fraud defense, fraud prevention, fraud schemes, government health programs, health law firm, Hope Cancer Institute, legal representation, medicare, medicare audit, Medicare fraud, Medicare overbilling, qui tam lawsuit, the health law firm, whistleblower, whistleblower lawsuit, whistleblower protection, whistleblower settlement|Comments Off