Posts Tagged ‘healthcare fraud’

James Hoyer Investigator Speaks at National Investigative Reporters Conference

IRE Speakers (l to r): Steve Becker, Andy Donahue, Nicole Hong, Angie Moreschi

Every year, the national Investigative Reporters and Editors (IRE) conference brings together many of the best investigative reporters in the United States and abroad. More than 2000 journalists attended IRE 2019 in Houston to learn investigative techniques and develop story ideas. High on the list: stories about fraud.

James Hoyer Investigator and Communications Director Angie Moreschi was invited to speak on a panel about detecting business fraud. For the presentation, she joined Wall Street Journal reporter Nicole Hong, Better Business Bureau International Investigations Specialist Steve Becker, and moderator Andy Donahue, editor of Reveal from the Center for Investigative Reporting.

“These are some of the smartest and best reporters in the world, so it’s always an honor and privilege to speak at the IRE conference. I try to offer useful, practical tips on how to find fraud against the government and ideas to help reporters tell these important stories to public,” Angie said.

The False Claims Act & Whistleblowers

Angie shared important information about how whistleblowers help to expose fraud against the government through the False Claims Act and how they help to recover money for taxpayers.

The False Claims Act is the law that makes it possible for private citizens to file suit on behalf of the government when they become aware of fraud at companies ripping off government agencies or programs.  Through these whistleblower suits, the Department of Justice recovered $2.8 billion, last year alone.

There’s a lot of fraud out there and it takes many forms, from improper patient admissions, over-billing, and up-coding at hospitals;  kickbacks for referrals; selling unnecessary medical equipment; pharmaceutical companies pushing the sale of drugs off-label; defense contractor fraud; and financial aid fraud.

Fastest Growing Types of Fraud

Healthcare fraud is far and away the number one type of fraud against the government, with DOJ estimating some $100 billion lost to healthcare fraud, every year.

One of the fastest growing areas is Durable Medical Equipment fraud. This is where unscrupulous companies often target senior citizens on Medicare and harass them with multiple phone calls everyday, trying to get them to authorize shipments of medical equipment or products. The big problem is many patients don’t need or want the items, but in several cases, the companies ship them anyway, and then fraudulently bill the government.

“It’s something all taxpayers should care about, because we all pay for it,” Angie said.

Presentation by Other Panelists

In addition to Angie’s presentation, Wall Street Journal reporter Nicole Hong talked about some of the biggest fraud cases covered by the paper, this year; and BBB investigator Steve Becker looked at some of the top areas of consumer fraud, including online romance scams, puppy scams, and business email scams.

 

“Fountain of Youth” Doctor Convicted in Healthcare Fraud Scheme

Picture courtesy of Connect Media

A Pittsburgh area cardiologist was found guilty of two counts of healthcare fraud, involving more than $13 million in falsified insurance billing. Dr. Samirkumar Shah submitted the fraudulent claims to Medicare, Medicaid and several private insurance companies and received payments in excess of $3.5 million.

During an eight day trial, evidence was submitted to show that Dr. Shah, 56, offered External Counter Pulsation (ECP) treatments to patients in Pennsylvania, Ohio, New York and Florida for a variety of ailments, including obesity, migraines and erectile dysfunction. He advertised the ECP treatments as “the Fountain of Youth” and claimed they made patients “younger and smarter,” according to the Department of Justice.

ECP involves the use of a specialized bed equipped with pressure cuffs, which exert pressure upon patients’ lower extremities as a means to increase blood flow to the heart.  Insurers only reimburse for ECP treatments for patients who suffer from disabling angina—or chest pain caused by decreased blood flow to the heart—and only when a physician supervised the treatment.

FBI Pittsburgh Special Agent in Charge Robert Jones called healthcare fraud a serious problem that impacts every American. “It takes critical resources from our health care system and increases health care costs for everyone. Dr. Shah’s disregard for safe patient care goes against the medical ethics he was to uphold,” Jones said.

According to the DOJ, evidence showed that Shah instructed his employees to indicate that every patient had disabling angina on billing sheets that were used to support false insurance claims. In some cases, Shah never even met patients and never reviewed ultrasound imagery before approving new patients to begin ECP. In addition to billing for ECP treatments that were not medically necessary and were not provided under direct physician supervision, Shah also double-billed insurers.

Contrary to health insurance requirements, ECP treatments routinely occurred while neither Shah nor any other medical doctor was present at his various locations. On one occasion, a patient experienced an adverse event during his ECP treatment and had to be transported via ambulance to the hospital.

U.S. Attorney Scott Brady said, “Health care fraud threatens the safety and integrity of our entire health care system. Doctors and medical professionals like Dr. Shah who issue false diagnoses, order unnecessary testing and fraudulently bill Medicare and Medicaid in effect steal from the most vulnerable in our community.”

Shah faces a maximum sentence of 10 years in prison, a fine of $250,000, or both.  Click here to read more from the Department of Justice.

 

$65 Million Prime Healthcare Whistleblower Settlement

Prime Whistleblower

Whistleblower’s Fearless 7-Year Pursuit of Justice:

Los Angeles, CA- August 3, 2018— The 5th largest for-profit hospital system in the country has agreed to pay $65 million to settle civil charges of healthcare fraud against the government. Prime Healthcare has also agreed to abide by a Corporate Integrity Agreement with strict requirements and oversight to ensure it will follow Medicare rules in the future. Prime, headquartered in Ontario, CA, has 45 hospitals in 14 states. It was a long-fought battle against the healthcare giant lasting nearly a decade, but whistleblower Karin Berntsen is grateful to finally see Prime held accountable.  Read More…

 

Freedom Health Pays $32.5 Million to Settle False Claims Act Case

The James Hoyer law firm served as local counsel in a whistleblower case against Freedom Health, which provides managed care services.  Freedom agreed to pay a total of $32.5 million to resolve allegations that it engaged in illegal schemes to maximize payments from the government for it’s Medicare Advantage plans. Here is the Department of Justice news Release:

Medicare Advantage Organization and Former Chief Operating Officer to Pay $32.5 Million to Settle False Claims Act Allegations

Freedom Health Inc., a Tampa, Florida-based provider of managed care services, and its related corporate entities (collectively “Freedom Health”), agreed to pay $31,695,593 to resolve allegations that they violated the False Claims Act by engaging in illegal schemes to maximize their payment from the government in connection with their Medicare Advantage plans, the Justice Department announced today. In addition, the former Chief Operating Officer (COO) of Freedom Health Siddhartha Pagidipati, has agreed to pay $750,000 to resolve his alleged role in one of these schemes.

“When entering into agreements with managed care providers, the government requests information from those providers to ensure that patients are afforded the appropriate level of care,” said Acting Assistant Attorney General Chad A. Readler of the Justice Department’s Civil Division. “Today’s result sends a clear message to the managed care industry that the United States will hold managed care plan providers responsible when they fail to provide truthful information.”

The government alleged that Freedom Health submitted or caused others to submit unsupported diagnosis codes to CMS, which resulted in inflated reimbursements from 2008 to 2013 in connection with two of their Medicare Advantage plans operating in Florida. It also alleged that Freedom Health made material misrepresentations to CMS regarding the scope and content of its network of providers (physicians, specialists and hospitals) in its application to CMS in 2008 to expand in 2009 into new counties in Florida and in other states. The government’s settlement with Mr. Pagidipati resolves his alleged role in this latter scheme.

“Medicare Advantage plans play an increasingly important role in our nation’s health care market,” said Acting U.S. Attorney Stephen Muldrow. “This settlement underscores our Office’s commitment to civil health care fraud enforcement.”

“Medicare Advantage insurers must play by the rules and provide Medicare with accurate information about their provider networks and their patients’ health,” said Chief Counsel to the Inspector General Gregory Demske of the Department of Health and Human Services Office of Inspector General (HHS-OIG). “OIG will investigate and hold managed care organizations accountable for fraud. Moving forward, the innovative CIA reduces the risks to patients and taxpayers by focusing on compliance issues unique to Medicare Advantage plans.”

The allegations resolved by these settlements were brought in a lawsuit under the qui tam, or whistleblower, provisions of the Federal False Claims Act and the Florida False Claims Act. These statutes permit private parties to sue on behalf of the government for false claims and to receive a share of any recovery. The whistleblower in this action is Darren D. Sewell, who was a former employee of Freedom Health. The whistleblower’s share in this case has not yet been determined.

The corporate entities related to Freedom and which were part of today’s settlements are: Optimum HealthCare Inc., America’s 1st Choice Holdings of Florida LLC, Liberty Acquisition Group LLC, Health Management Services of USA LLC, Global TPA LLC, America’s 1st Choice Holdings of North Carolina LLC, America’s 1st Choice Holdings of South Carolina LLC, America’s 1st Choice Insurance Company of North Carolina Inc. and America’s 1st Choice Health Plans Inc.

Today’s settlements were the result of a coordinated effort by the Civil Division’s Commercial Litigation Branch, The U.S. Attorneys’ Office for the Middle District of Florida, HHS-OIG and the Florida Office of the Attorney General.

The claims resolved by the settlements are allegations only, and there has been no determination of liability. The case is captioned United States ex rel. Sewell v. Freedom Health, Inc., et al., Case No. 8:09-cv-1625 (M.D. Fla.).

 

Federal Government Joins Prime Healthcare Whistleblower Suit

Karin-1-medium

Prime Healthcare Whistleblower Karin Berntsen

The federal government is joining the whistleblower case of James Hoyer client Karin Berntsen against Prime Healthcare Services, its founder Dr. Prem Reddy, and more than a dozen of its hospitals.  Prime is a fast growing company that owns more than 40 hospitals nationwide.

The whistleblower suit, which was unsealed in December of 2013, alleges Prime improperly admitted patients through its emergency rooms to increase payments from Medicare.

James Hoyer partner Elaine Stromgren called the government’s intervention “a significant development which shows the seriousness of the allegations and the strength of the evidence supporting those claims.”

The Department of Justice news release explains some of the key allegations:

The lawsuit alleges that Dr. Reddy directed the corporate practice of pressuring Prime’s Emergency Department physicians and hospital administrators to raise inpatient admission rates, regardless of whether it was medically necessary to admit the patients.  The lawsuit alleges that Prime’s corporate officers, at Reddy’s direction, exerted immense pressure on doctors in the Emergency Departments to admit patients who could have been placed in observation, treated as outpatients or discharged.  As a result of these medically unnecessary admissions from the Emergency Departments, Prime hospitals allegedly submitted false claims to federal health care programs, such as Medicare.

Whistleblower Karin Berntsen remains in her position at Alvarado Hospital in San Diego as Director of Performance Improvement.  She came forward to expose these practices because she believes they put  patients at risk in order to increase profit.

DOJ says the government’s intervention in this case shows its emphasis on combating health care fraud:

“The Department of Justice is committed to ensuring that health care providers do not inappropriately seek to profit at the expense of federal health care programs,” said Principal Deputy Assistant Attorney General Benjamin C. Mizer, head of the Justice Department’s Civil Division.  “Schemes such as this one can contribute significantly to the rising cost of health care delivery and create needless patient risk.”

“Fraudulent billing practices, such as those alleged in this civil lawsuit, harm taxpayers who fund health care programs, such as Medicare,” said U.S. Attorney Eileen M. Decker for the Central District of California.  “The Justice Department works collaboratively with law enforcement agencies, regulators and, in some cases, private citizens to ensure the integrity of a system that provides healthcare to millions of Americans.”

“Charging for medically unnecessary services, as alleged in this case, raises costs in government health programs and remorselessly passes that bill along to taxpayers,” said Special Agent in Charge Christian J. Schrank of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG).  “Our investigation into the allegations in this case, along with our law enforcement partners, led to the government’s decision to intervene.”

Contact Us ButtonThe whistleblower suit also alleges that Prime would “upcode” patient diagnoses to make them appear more serious, in order to get additional Medicare payments.  The James Hoyer firm will continue to vigorously pursue this count as well.

Multiple news outlets reported on the significant development, including the Center for Investigative Reporting, Wall Street Journal, Los Angeles Times, San Diego Union TribuneModern Healthcare, and Becker’s Hospital Review, among others.