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Fifty-Five Hospitals Around the Country to Pay the Government $34 Million Settlement for False Claims Allegations

10 Indest-2008-7By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

Fifty-five (55) hospitals in twenty-one (21) states have agreed to pay the Department of Justice (DOJ) more than $34 million to settle allegations of Medicare fraud in a whistleblower case, according to the DOJ on July 2, 2013. The false claims allegations involve a back procedure called a kyphoplasty. The kyphoplasty can be performed safely and effectively as an outpatient procedure. However, it is alleged that hospitals were using more expensive, inpatient procedures to increase Medicare billings.

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

A kyphoplasty is used to treat spinal fractures usually caused by osteoporosis.

Fourteen (14) Florida Hospitals to Pay $11 Million to Government.

According to an article on Health News Florida, fourteen (14) Florida hospitals have agreed to pay around $11 million to settle the DOJ’s false claims charges.

One of the Florida hospitals was Mount Sinai Medical Center in Miami, which will pay $1.84 million. A number of HCA hospitals in Florida were included in the settlement. These hospitals will pay $7.14 million collectively. Another group that settled was the hospitals in the Morton Plant Mease group, which is part of the Baycare Health System in Tampa Bay. This settlement was listed at $2.37 million.

To see all of the Florida hospitals allegedly involved, click here to read the Health News Florida article.

Whistleblower Lawsuit Filed by Two Former Employees.

According to the DOJ, all but four of the settling facilities were named as defendants in a whistleblower lawsuit brought under the False Claims Act. The lawsuits were filed by a former reimbursement manager for Kyphon and a former regional sales manager for Kyphon. The DOJ stated that Kyphon is the company that allegedly advised hospitals to do kyphoplasty procedures as inpatient instead of outpatient procedures. These two will receive a total of about $5.5 million from the settlements.

If you want to know more about whistleblower/qui tam lawsuits, click here to read the first part of a two-part blog, and click here for the second part.

Previous Settlements from Kyphoplasty Procedures.

A similar settlement was reached in 2012, when 14 hospitals agreed to pay a settlement of more than $12 million to the government for allegedly inflating their profits based on unnecessary hospital admissions, according to the Washington Post. Click here to read that article.

The DOJ stated that it has now reached settlements with more than 100 hospitals, for a total of about $75 million resolving allegations that the facilities fraudulently billed Medicare for kyphoplasty procedures.

The Health Care Fraud Prevention and Enforcement Action Team (HEAT) is on Fire.

These settlements are a part of the government’s fight against health care fraud and another win for the Health Care Fraud Prevention and Enforcement Action Team (HEAT). HEAT’s mission is to focus its efforts on preventing and deterring fraud and to enforce current anti-fraud laws around the country. It was created in 2009, by the Department of Health and Humans Services (HHS) and the DOJ. To date, the DOJ’s total recoveries in False Claims Act cases since January 2009, are more than $14.7 billion. To learn more about HEAT, click 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 of these settlements? Please leave any thoughtful comments below.

Sources:

Department of Justice. “Fifty-Five Hospitals to Pay U.S. More Than $34 Million to Resolve False Claims Act Allegations Related to Kyphoplasty.” Department of Justice. (July 2, 2013). From: http://www.justice.gov/opa/pr/2013/July/13-civ-745.html

Associated Press. “Justice Department, 55 Hospitals Reach $34 Million Settlement Over Medicare Fraud Claims.” Washington Post. (July 2, 2013). From: http://www.washingtonpost.com/business/justice-department-55-hospitals-reach-34-million-settlement-over-medicare-fraud-claims/2013/07/02/3d3d2356-e34e-11e2-bffd-37a36ddab820_story.html

Health News Florida Staff. “14 FL Hospitals to Pay $11 Million.” Health News Florida. (July 2, 2013). From: http://health.wusf.usf.edu/post/14-fl-hospitals-pay-11-million

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.

Florida Hospice to Pay $1 Million to Settle Whistleblower Lawsuit Over False Billing Claims

10 Indest-2008-7By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

The Hernando-Pasco Hospice (HPH Hospice) in Hudson, Florida, agreed to pay $1 million to resolve allegations that it violated the False Claims Act by submitting false claims for services to the Medicare and Medicaid Programs. According to the U.S. Attorney’s Office for the Middle District of Florida, the hospice allegedly admitted patients that did not meet the requirements for end-of-life care. This lawsuit was originally filed in 2010, by two former hospice employees. The announcement was made on July 22, 2013.

Click here to read the entire press release from the U.S. Attorney’s Office for the Middle District of Florida.

Hospice Accused of Admitting Ineligible Patients to Meet Targets.

HPH Hospice is accused of admitting ineligible patients in order to meet targets imposed by the management team, according to federal authorities. The settlement also resolves allegations that the hospice billed the government at higher rates than it was entitled to receive. It’s also accused of providing illegal kickbacks by giving services to skilled nursing facilities at no cost, in exchange for patient referrals.

Two former employees of the hospice first stepped forward with these allegations. The employees were longtime social workers at HPH Hospice. They filed a lawsuit alleging the facility’s management instructed the staff to make false or misleading statements in patients’ medical records to make them appear eligible for hospice care. The two former employees will share $250,000 of the settlement.

HPH Hospices Claims No Wrongdoing.

According to the Tampa Bay Times, the HPH Hospice spokesperson said the allegations were completely false. The organization stated that the settlement was the better option for patients and staff. As a result of these allegations, HPH Hospice said that it has hired three registered nurses to review and monitor all admission documentation, according to the Tampa Bay Times.

To read the entire Tampa Bay Times article, click here.

Under the False Claims Act, Whistleblowers Can Come Out on Top.

Whistleblowers stand to gain substantial amounts, sometimes as much as thirty percent (30%), of the award under the False Claims Act (31 U.S.C. Sect. 3730). Such awards encourage employees to come forward and report fraud.

You can learn more read our two part blog on whistleblowers. Click here for part 1, and click here for part 2.

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

In addition to our other experience in Medicare, Medicaid and Tricare cases, attorneys with The Health Law Firm also represent health care professionals and health facilities in qui tam or whistleblowers 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 learn more on our experience with Medicaid and Medicare quit tam or whistleblower cases, visit our website. 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 agreement? Do you think settling was a better option for the hospice? Please leave any thoughtful comments below.

Sources:

Department of Justice. “HPH Hospice to Pay $1 Million to Resolve False Claims Act Allegations.” Department of Justice. (July 22, 2013). From: http://www.justice.gov/usao/flm/press/2013/july/20130722_HPH.html

Tillman, Jodie. “Hernando-Pasco Hospice Agrees to Pay $1 Million to Settle False Billing Cliams.” Tampa Bay Times. (July 22, 2013). From: http://www.tampabay.com/news/health/hernando-pasco-hospice-agrees-to-pay-1-million-to-settle-false-billing/2132592?utm_source=twitterfeed&utm_medium=twitter

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.

Halifax Whistleblower Claims Hospital Overbilled Medicare

The U.S. Department of Justice has joined a whistleblower suit filed against Halifax Hospital by the hospital’s director of physician services, according to the Daytona Beach News-Journal.

The U.S. Department of Justice filed its part of the lawsuit on Friday. It claims that Halifax Health defrauded the federal government by submitting thousands of false claims for Medicare and Medicaid payments worth millions of dollars. By filing, the U.S. Department of Justice hopes to recover millions of dollars in Medicare and Medicaid payments that it says were made in error to Halifax.

Elin Baklid-Kunz filed a lawsuit against Halifax in 2009. As a whistleblower, he could be awarded a percentage of whatever the government recovers. Generally, whistleblowers can be awarded 25 percent to 30 percent of the recovery. He claims Halifax overbilled Medicare by inappropriately admitting patients and had financial arrangements with some of its doctors that violated a federal anti-kickback law.

The federal Stark Law prohibits Medicare and Medicaid payments for hospital services that are prescribed by doctors who have profit-sharing agreements with the hospital. The law was made to ensure that referrals are made for medical reasons only, without financial motives.

However, according to the lawsuit, Halifax had agreements with its doctors that gave them a financial incentive to generate hospital revenues.

The Justice Department’s lawsuit focuses on doctors’ contracts, claiming that Halifax administrators “could not have reasonably concluded” the agreements to pay bonuses to doctors did not violate the Stark Law. Neurosurgeons at Halifax received generous incentive compensation that boosted their based salaries by hundreds of thousands of dollars. These neurosurgeons referred patients to Halifax and, between 2004 and 2010, Halifax charged Medicare more than $35 million for neurological services, the suit states. Each neurosurgeon individually generated over $2 million in profits for Halifax Hospital in 2009, according to the suit. The Justice Department claims a similar pattern existed with the hospital’s seven oncologists.

For more information on similar legal matters, visit www.TheHealthLawFirm.com.

Oncologist Accused of Billing Medicare for Unnecessary Chemotherapy-Employee Whistleblowers Filed First Claim

4 Indest-2009-3By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

A Michigan oncologist is accused of deliberately misdiagnosing patients with cancer so he could allegedly administer chemotherapy treatments and bill the government for those treatments, according to the Department of Justice (DOJ). For more than two years the oncologist allegedly billed Medicare for $35 million in fraudulent claims. The oncologist was charged on August 19, 2013, with one count of Medicare fraud, according to the DOJ.

On top of submitting false claims to Medicare, a criminal complaint alleges a number of other serious charges. These include hiring doctors who may not have been properly licensed to practice medicine, administering controlled substances to patients at dangerous levels, and delaying hospital care for a patient with serious injuries, among others.

The complaint is allegedly based on interviews with several nurse practitioners, medical assistants and another doctor who worked for the oncologist at Michigan Hematology Oncology Centers (MHO), according to the DOJ. These whistleblowers allegedly approached federal authorities with this information.

Click here to read the press release from the DOJ.

We are aware of similar stories regarding dermatologists misdiagnosing lesions as cancer. Some of these have been widely publicized in media reports, television news and magazine stories, such as “American Greed.”

Whistleblowers Come Forward with Serious Charges Against Oncologist.

The oncologist’s employees allege the doctor submitted fraudulent claims to Medicare for medically unnecessary services, including chemotherapy treatments, Positron Emission Tomograph (PET) scans, and a variety of cancer and hematology treatments for patients who did not need them. According to an article in Time, the complaint also alleges the oncologist administered unnecessary chemotherapy to patients in remission, deliberately misdiagnosed patients as having cancer to justify unnecessary cancer treatment, and administered chemotherapy to end-of-life patients who would not have benefitted from the treatment.

The criminal complaint also alleges, according to Time, that the oncologist distributed controlled substances to patients without medical necessity and employed foreign doctors who might have been unlicensed to practice medicine in the U.S.

According to Time, the complaint also cited one case in which the oncologist’s patient fell and hit his head at the oncologist’s office, and was told he needed chemotherapy before he could be taken to the hospital. The patient allegedly later died from the head injury.

Click here to read the entire Time article.

Oncologist Faces Prison Time and Fine.

According to Detroit News, the oncologist could face up to 10 years in prison and a $250,000 criminal fine if convicted. The oncologist has entered a not guilty plea in this case. At this point, these accusations are just that, allegations. A check of the oncologist’s license status from the Michigan Department of Health (DOH) shows that his license is active.

To read the Detroit News article, click here.

Most Qui Tams Filed by Doctors, Nurses and Employees.

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 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.

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. “Oakland County Doctor and Owner of Michigan Hemotology and Oncology Centers Charged in $35 Million Medicare Fraud Scheme.” Department of Justice. (August 6, 2013). From: http://www.justice.gov/opa/pr/2013/August/13-crm-885.html

Pickert, Kate. “Medicare Fraud Horror: Cancer Doctor Indicted for Billing Unnecessary Chemo.” Time U.S. (August 15, 2013). From: http://nation.time.com/2013/08/15/medicare-fraud-horror-cancer-doctor-indicted-for-billing-unnecessary-chemo/

Hunter, George. “Michigan Cancer Doctor Formally Charged in Medicare Fraud Scheme.” Detroit News. (August 19, 2013). From: http://bit.ly/14T8A2A

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.

Walgreens Reaches Settlement in False Claims Act Case

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

Walgreens has reached a $7.9 million settlement with the United States and participating states that resolves allegations that Walgreens violated the False Claims Act. The DOJ announced the settlement on April 20, 2012. To view the DOJ’s press release concerning the settlement with Walgreens, click here. To view the False Claims Act, click here.

Walgreens Allegedly Offered Illegal Inducements to Medicare and Medicaid Beneficiaries.

The settlement was reached after Walgreens was accused of offering illegal inducements to beneficiaries of government health programs (Medicare, Medicaid, the Federal Employees Health Benefits Program (FEHBP), and TRICARE ). Walgreens allegedly offered gift cards to government health program beneficiaries when they transferred a prescription from another pharmacy to Walgreens. The government maintains that such inducements are a violation of state and federal laws.

Walgreens Pays Back Individual State Medicaid Programs.

Since the initial settlement was announced by the DOJ, Walgreens has begun to pay back individual state Medicaid programs that were impacted by the alleged inducements. State and federal laws prohibit such inducements to buy services and goods provided under Medicaid. Walgreens is now paying the states for prescription claims it submitted for reimbursement to Medicaid that were a result of the alleged inducements. Some of the states involved include California, Indiana, Michigan, and Missouri.

Whistleblowers Initiated Government Investigation of Walgreens’ Gift Card Inducements.

The allegations were brought to the government by two whistleblowers. Two separate whistleblower lawsuits were filed under the qui tam, or whistleblower, provisions of the False Claims Act and state False Claims Act statutes. The whistleblowers will receive $1,277,172 from the United States for their role in filing the qui tam actions.

Contact Health Law Attorneys Experienced with False Act Claims Cases.

The Health Law Firm represents physicians, medical practices, pharmacists, pharmacies, and other health provider in investigations, regulatory matters, licensing issues, litigation, inspections and audits involving government health programs (Medicare, Medicaid, TRICARE). The Health Law Firm also represents health providers in False Claims Act cases.

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

Sources Include:

Cohen, Bryan. “Whistleblower Lawsuits Against Walgreens Settled.” LegalNewsline. (June 12, 2012). From: http://www.legalnewsline.com/news/236427-whistleblower-lawsuits-against-walgreens-settled

Department of Justice, Office of Public Affairs. “Walgreens Pharmacy Chain Pays $7.9 Million to Resolve False Prescription Billing Case.” Department of Justice. (April 20, 2012). Press Release. From: http://www.justice.gov/opa/pr/2012/April/12-civ-505.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.

New York-Based MRI Company to Pay $3.57 Million Settlement to Resolve False Claims Act Allegations in Whistleblower/Qui Tam Case

6 Indest-2008-3By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

On August 27, 2013, the Department of Justice (DOJ) announced a settlement between the government and New York-based Imagimed LLC, its former owners and its former chief radiologist. This $3.57 million settlement resolves whistleblower/qui tam allegations of false reimbursement claims for radiology scans. The payment also settles accusations that the company violated the Stark Law and the Anti-Kickback Statute.

Click here to read the press release from the DOJ.

Imagimed owns and operates 15 magnetic resonance imaging (MRI) facilities under the name Open MRI.

MRI Company Accused of Not Following Proper Safety Precautions and Committing Health Care Fraud.

According to the DOJ, from July 2001 through April 2008, Imagimed, the company’s former owners and the former chief radiologist submitted claims to Medicare, Medicaid and TRICARE for MRI scans performed with a contrast dye without the direct supervision of a qualified doctor, as required by federal regulations.

The DOJ also alleges that from July 2005 to April 2008, Imagimed also had sham on-call arrangements with, and gave improper gifts to referring physicians, which is in violation of the Stark Law and the Anti-Kickback Statute.

Local Radiologist Blew Whistle and Receives a Cut of the Settlement.

According to the Associated Press, a local radiologist filed the lawsuit against Imagimed under the False Claims Act. The radiologist will receive $565,500 for coming forward. To read the Associated Press article, click here.

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. Section 3730). Such awards encourage employees and contractors to come forward and report fraud. To learn more on whistleblower 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 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:

Department of Justice. “MRI Diagnostic Testing Company, Imagimed LLC, and Its Former Owners and Chief Radiologist to Pay $3.57 Million to Resolve False Claims Allegations.” Department of Justice. (August 27, 2013). From: http://www.justice.gov/opa/pr/2013/August/13-civ-958.html

Associated Press. “Federal Authorities Settle MRI Case for $3.75M.” The Wall Street Journal. (August 29, 2013). From: http://online.wsj.com/article/APcf5d7d677786468bb9d446b6c3082e5d.html?KEYWORDS=medicare

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.

WellCare Health Plans Reaches Settlement in False Claims Act Case

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

WellCare Health Plans Inc.(WellCare) has reached a $137.5 million settlement with the federal government and nine states. The settlement resolves four lawsuits alleging violations of the False Claims Act.

WellCare is based in Tampa, Florida. The company provides managed health care services for approximately 2.6 million Medicare and Medicaid beneficiaries across the United States.

Lawsuits Allege WellCare Submitted False Claims to Medicare, Medicaid Programs.

The lawsuits allege that WellCare submitted false claims to Medicare and Medicaid programs. WellCare allegedly falsely inflated the amount it claimed to be spending on medical care. Allegedly, this was done in order to avoid returning money to Medicaid and other programs in various states, including the Florida Medicaid program and Florida Healthy Kids program. WellCare also allegedly knowingly retained overpayments it had received from Florida Medicaid for infant care. Furthermore, WellCare allegedly falsified data that misrepresented the medical conditions of patients and the treatments they received.

WellCare to Pay the United States and Nine Individual States in Settlement.

WellCare’s settlement requires the company to pay the United States and nine individual states $137.5 million. The nine states are Connecticut, Florida, Georgia, Hawaii, Illinois, Indiana, Missouri, New York, and Ohio. The settlement also requires WellCare to pay an additional $35 million if the company is sold or experiences a change in control within three years of the agreement.

Whistleblowers Share in Settlement.

The four lawsuits against WellCare were filed by whistleblowers under the qui tam provisions of the False Claims Act. The qui tam provisions allow individuals to file lawsuits on behalf of the United States and share in any recovery.

The whistleblower whose qui tam complaint initiated the government’s investigation will receive approximately $20.75 million. The other whistleblowers will share approximately $4.66 million and will also be entitled to receive an additional share of any contingency payment.

Contact Health Law Attorneys Experienced in False Claims Act Cases.

The Health Law Firm represents physicians, medical practices, pharmacists, pharmacies, and other health provider in investigations, regulatory matters, licensing issues, litigation, inspections and audits involving government health programs (Medicare, Medicaid, TRICARE). The Health Law Firm also represents health providers in False Claims Act cases.

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

Sources Include:

Kutscher, Beth. “WellCare Agrees to Pay Over $137.5 Million in Settlement.” Modern Healthcare. (Apr. 3, 2012). From: http://www.modernhealthcare.com/article/20120403/NEWS/304039975#ixzz1yAklA7rutrk=tynt

U.S. Department of Justice, Office of Public Affairs. “Florida-Based WellCcare Health Plans Agrees to Pay $137.5 Million to Resolve False Claims Act Allegations.” U.S. Department of Justice. (Apr. 3, 2012). From: http://www.justice.gov/opa/pr/2012/April/12-civ-425.html

Voreacos, David. “WellCare to Pay $137.5 Million to Settle False Claims Case.” Bloomberg News. (Apr. 3, 2012). From: http://www.bloomberg.com/news/2012-04-03/wellcare-to-pay-137-5-million-to-settle-false-claims-case-1-.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.

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

6 Indest-2008-3By 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.

Settlement Reached in GlaxoSmithKline Healthcare Fraud Case

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

GlaxoSmithKline (GSK), a prescription drug manufacturer, will pay $3 billion in fines to resolve allegations of healthcare fraud. The settlement was announced by federal prosecutors on July 1, 2012, and in a press release from the Florida Attorney General on July 2, 2012. This is the largest healthcare fraud settlement in U.S. history.

Settlement Resolves Allegations Against GSK Related to Healthcare Fraud.

The settlement resolves allegations that GSK:

  • Marketed the depression drug Paxil for off-label uses, such as use by children and adolescents; 
  • Marketed the depression drug Wellbutrin for off-label uses, such as for weight loss and treatment of sexual dysfunction, and at higher-than-approved dosages; 
  • Marketed the asthma drug Advair for off-label uses, including first-line use for asthma;
  • Marketed the seizure medication Lamictal for off-label uses, including bipolar depression, neuropathic pain, and various other psychiatric conditions; 
  • Marketed the nausea drug Zofran for off-label uses, including pregnancy-related nausea; 
  • Made false representations regarding the safety and efficacy of Paxil, Wellbutrin, Advair, Lamictal, Zofran, and the diabetes drug Avandia;
  • Offered kickbacks to healthcare professionals to induce them to promote and prescribe certain prescription drugs; and
  • Submitted incorrect pricing data for various prescription drugs, thereby underpaying rebates owed to Medicaid and other federal healthcare programs.

GSK Will Also Plead Guilty to Criminal Charges as Part of Settlement.

As part of the settlement, GSK has will plead guilty to criminal charges that it violated the federal Food, Drug, and Cosmetic Act (FDCA). Allegedly, GSK introduced Wellbutrin and Paxil into interstate commerce when the drugs contained labels that were not in accordance with their FDA approvals. Additionally, GSK allegedly failed to report certain clinical data regarding Avandia to the FDA.

Florida to Receive Over $56 Million In Settlement.

Florida will receive more than $56 million as part of the settlement with GSK. Florida Attorney General, Pam Bondi, announced the state’s participation in the settlement on July 2, 2012.

Settlement Stems From Whistleblower Actions.

The settlement is based on four qui tam, or whistleblower, actions brought by individuals pursuant to state and federal false claims. To view the federal False Claims Act, click here. A National Association of Medicaid Fraud Control Units team, along with several other federal agencies, investigated the matter and conducted settlement negotiations with the defendants. Florida’s civil investigation was handled by the Attorney General’s Complex Civil Enforcement Bureau, which is part of the Medicaid Fraud Control Unit.

Contact Health Law Attorneys Experienced in Healthcare Fraud Cases.

The Health Law Firm represents physicians, medical practices, pharmacists, pharmacies, and other health providers in healthcare fraud cases, including investigations, regulatory matters, litigation, and audits involving government health programs (Medicare, Medicaid, TRICARE).

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

Sources Include:

Meale, Jenn. “Attorney General Bondi’s Office Reaches Historic Healthcare Fraud Settlement.” Florida Office of the Attorney General. (July 2, 2012). Press Release. From: http://www.myfloridalegal.com/newsrel.nsf/newsreleases/E494FDADFF113AC885257A2F0068F790

Schmidt, Michael S. and Katie Thomas. “GlaxoSmithKline Agrees to Pay $3 Billion in Fraud Settlement.” New York Times. (July 2, 2012). From: http://www.nytimes.com/2012/07/03/business/glaxosmithkline-agrees-to-pay-3-billion-in-fraud-settlement.html?pagewanted=all

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.

Tuomey Healthcare System Ordered to Pay a Reduced $238 Million in Damages for Allegedly Violating Stark Law and False Claims Act

LOL Blog Label 2Lance O. Leider, J.D., The Health Law Firm and George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

On September 30, 2013, a federal judge ordered Tuomey Healthcare System in Sumter, South Carolina, to pay $238 million in penalties and fines. The hospital system is accused of paying doctors to refer Medicare patients for treatments at the hospital, according to a number of media sources. The judge granted the government’s request to impose Stark law penalties and False Claims Act fines. The lawsuit against Tuomey was initially filed in 2005, by a whistle-blowing physician.

This corrected fine actually lowers the amount originally ordered by the federal judge, reducing it by $39 million. The original judgement was for approximately $277 million. The reduction in the damages was an acknowledgment that there was an error in the calculation of damages by the judge in the case, who awarded more than the government asked for.

Click here to read the entire ruling from the federal judge.

After the judge announced the fines, Tuomey began preparing to file an appeal, according to an article on Modern Healthcare. It is alleged that the hospital may be looking to settle.

Judge Ordered Hospital System to Pay Fines for Violating Stark Law and False Claims Act.

In a 2005 federal whistleblower or qui tam lawsuit, a Tuomey physician stated that a series of 19 deal contracts with specialty physicians in the area violated the federal ban on compensating doctors based on the volume and value of patient business they refer, according to Modern Healthcare. This is considered to be a financial conflict, illegal under federal laws.

The hospital has twice lost its case in U.S. District Court. A 2010, jury came to a $45 million split verdict that was overturned on appeal. In May 2013, a second jury found the hospital responsible for more violations than in the first trial, deciding that the hospital violated the Stark law and the False Claims Act.

It’s alleged that between 2005 and 2009, Tuomey collected $39 million in fraudulent Medicare claims.

To read the Modern Healthcare article, click here.

Open to Settlement.

According to WLTX, the CBS affiliate in Sumter, South Carolina, Tuomey is filing a notice of appeal. It is expected the hospital system is open to settle. According to a former attorney with the Department of Health and Human Services’ (HHS) Inspector General’s Office (OIG), it will be up to the government if they will settle. The former attorney also stated that with most of the civil litigation division on furlough it might take some time.

Complying with Stark and Other Anti-Fraud Laws.

The federal government has several tools in its toolbox to combat Medicare fraud. Among those are the Stark Act, Anti-Kickback laws, and Civil Monetary Penalty Laws. Each of these typically focuses on a particular type of behavior that is prone to abuse by health care providers.

Primarily, the Stark laws exist to combat the problems that can arise from physician self-referrals. Self-referrals are cases in which a physician orders a test or service and refers the patient to a provider in which the referring physician has a financial interest. This second provider will then bill Medicare for the service, essentially allowing the referring physician to cash in twice. Click here to read our previous blog on compliance with the Stark law.

Paying Kickbacks or Providing Things of Value in Exchange for Patient Referral Now Recognized as Basis for False Claims Act Cases.

U.S. v. Tuomey is just one of several different cases that has recently been decided that allows qui tam or whistleblower recoveries based on providing kickbacks for patient referrals. “Kickbacks” can include any thing or service of value. It can include, for example, tickets to ball games, free meals, sets of surgical scrubs, gift cards, appliances and free medical supplies. A “referral” can include an actual referral of a patient, a consultation to another physician, an order for x-rays, labs or other diagnostic testing, a prescription for medication, medical equipment or other supplies or services, an order for home health or nursing home services or other medical services.

It is the giving of something of value in exchange for the referral that violates the Stark Act and, many times, state laws. The theory is that this unnecessarily increases the amount of medical services that the government pays for without there being any actual medical need for them.

Now, under the decision in Tuomey and other cases, the claims for medical services (and equipment) that were submitted when the services (and equipment) were based on kickbacks, are considered to be false claims. Whistleblowers (qui tam plaintiffs or “relators”) can now file False Claims Act suits based on these theories and share in the government’s recovery. For example, and by way of demonstration only, if the person who filed the qui tam case in Tuomey received only 20% of the amount awarded to the government, that individual would receive approximately $47.6 million as their share. This is still big money to some of us.

Contact Health Law Attorneys Experienced in Handling Stark Compliance.

If you are involved in referring or providing DHS it is crucial that your arrangements are 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.

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 ruling? Please leave any thoughtful comments below.

Sources:

Calson, Joe. “Out-of-Court Settlement for Tuomey may be in te Works Following Ruling Against the System.” Modern Healthcare. (October 1, 2013). From: http://bit.ly/15Lj2uF

United State of America ex rel Michael L. Drakeford, M.D. vs. Tuomey d/b/a Tuomey Healthcare System, Inc. Case Number 3:05-cv-02858-MBS. Federal Judge Order and Opinion. September 30, 2013. From: http://www.thehealthlawfirm.com/uploads/Toumey%20Case.pdf

Santaella, Tony. “Tuomey Healthcare Ordered to Pay $276 Million.” WLTX. (October 1, 2013). From: http://www.wltx.com/news/story.aspx?storyid=251321

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

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