Posts Tagged ‘Medicaid’

$2.4 Billion Returned to Taxpayers in Healthcare Fraud Recoveries

The federal government recovered $2.4 billion from healthcare fraud judgments in 2015, according to the Department of Justice.  A portion of the money recovered came as the result of work by the Health Care Fraud and Abuse Control program, which coordinates federal, state and local law enforcement to fight healthcare fraud.

In addition, DOJ obtained more than $1.9 billion in settlements and judgments through the federal False Claims Act.  The False Claims Act makes it possible for private citizens to blow the whistle on healthcare fraud.  These individuals, referred to as relators, can file a lawsuit on behalf of the government to recover money improperly taken from programs like Medicaid and Medicare. The whistleblower can then receive a portion of any successful recovery as a reward.

Click here to read the DOJ news release.

 

Pfizer Settles Whistleblower Case on Heartburn Med Protonix for $785M

protonixPfizer has agreed to pay $784.6 million to settle claims that it overcharged Medicaid for its heartburn medicine Protonix. The agreement marks one of the biggest settlements to date from drugmakers facing similar allegations, according to FiercePharma.

In the case, in which the US Department of Justice joined a whistleblower lawsuit against Wyeth in 2009, the drugmaker was accused of failing to provide state Medicaid programs with the same discounts that were afforded to certain non-governmental customers, in violation of federal law. The Department of Justice estimated that as a consequence, Wyeth avoided paying hundreds of millions of dollars in rebates to Medicaid programs.

A physician and a former AstraZeneca  sales rep filed the two earlier whistleblower suits against Wyeth, according to a Wall Street Journal story. The U.S. False Claims Act allows individuals to file suits accusing companies or individuals of defrauding the government, and potentially get some money back for doing so.

The settlement “does not include an admission of liability” by Pfizer, and it is still subject to a final settlement agreement and court approval, the company said in a statement. But the agreement does mark the end of a long chapter for Pfizer, which inherited the case after buying Wyeth in 2009.

Pfizer, the largest U.S.-based drugmaker, said it is charging the payment to its fourth-quarter results, which it restated on Tuesday. That left the New York-based company with a loss of $172 million, or 3 cents per share, in the last quarter, compared with a net profit of $613 million, or 10 cents per share, initially reported on Feb. 2.

 

 

Expert: Fraud Leads to Poor Quality Healthcare

Photo by HFMA.org

Photo by HFMA.org

Harvard professor and healthcare expert Atul Gawande recently noted that the unnecessary medical care endangers patients and robs the taxpayers.  In a recent article published in The New Yorker, Gawande cited fraud as a significant contributor to what leading researchers describe as “low-value care.”  Gawande, a general surgeon, notes that ‘[d]octors get paid for doing more, not less,” and that a huge percentage of Medicare patients receive unnecessary and wasteful care.  You can read Dr. Gawande’s full article on The New Yorker’s website.


Excerpted in Part:

I am a general surgeon with a specialty in tumors of the thyroid and other endocrine organs. In my clinic that afternoon, I saw eight new patients with records complete enough that I could review their past medical history in detail. One saw me about a hernia, one about a fatty lump growing in her arm, one about a hormone-secreting mass in her chest, and five about thyroid cancer.

To my surprise, it appeared that seven of those eight had received unnecessary care. Two of the patients had been given high-cost diagnostic tests of no value. One was sent for an MRI after an ultrasound and a biopsy of a neck lump proved suspicious for thyroid cancer. (An MRI does not image thyroid cancer nearly as well as the ultrasound the patient had already had.) The other received a new, expensive, and, in her circumstances, irrelevant type of genetic testing. A third patient had undergone surgery for a lump that was bothering him, but whatever the surgeon removed it wasn’t the lump—the patient still had it after the operation. Four patients had undergone inappropriate arthroscopic knee surgery for chronic joint damage. (Arthroscopy can repair certain types of acute tears to the cartilage of the knee. But years of research, including randomized trials, have shown that the operation is of no help for chronic arthritis- or age-related damage.)

Virtually every family in the country, the research indicates, has been subject to overtesting and overtreatment in one form or another. The costs appear to take thousands of dollars out of the paychecks of every household each year. Researchers have come to refer to financial as well as physical “toxicities” of inappropriate care—including reduced spending on food, clothing, education, and shelter. Millions of people are receiving drugs that aren’t helping them, operations that aren’t going to make them better, and scans and tests that do nothing beneficial for them, and often cause harm.

 

 

Whistleblower Doctor Stands Up against Indiana’s Largest Hospital System: Says Care Compromised for Low Income Pregnant Women

Dr. Judith Robinson Picture

Dr. Judith Robinson

James Hoyer law firm client Dr. Judith Robinson is a well-respected Obstetrician/Gynecologist who’s practiced in Indianapolis for 30 years. She chose to come forward as a whistleblower and put her career on the line after witnessing a violation of Medicaid rules, which she believes put pregnant women and their babies at risk. The Indianapolis Star reported on Dr. Robinson’s recently unsealed False Claims Act case in a front page story in today’s paper.

Dr. Robinson was in a unique position to realize pregnant women on Medicaid who had high risk complications were being cared for by midwives, instead of doctors, in violation of Medicaid rules.  Dr. Robinson was both Medical Director of Ob/Gyn Services at Methodist Hospital, a  safety net Indiana University Hospital and Director of Women’s Services at HealthNet, which provides health care to the medically under served.

She repeatedly tried to get the hospital administration to address the need to have doctors treat high risk patients and not midwives. She documented 17 cases which resulted in emergencies, three of which resulted in permanent neurological damage to the babies and one maternal death.

Despite these serious issues, her efforts to correct the situation were rebuffed by the hospital administration multiple times and she was ultimately fired.  Dr. Robinson presented evidence in her whistleblower suit to show the hospital chose to use midwives, instead of doctors, to save money.  She refused to stay silent and is speaking out in the hopes that this practice will be stopped.

WTHR TV in Indianapolis profiled Dr. Robinson’s case as the lead story on its 6pm newscast.  Play the video below to watch.

Dr. Robinson now practices at another hospital in Indianapolis. Click here to read more about her courageous stand against Indiana’s largest hospital system.

Dr. Robinson is represented by James Hoyer attorneys Jillian Estes and Chris Casper, as well as, co-counsel Robert Saint of Indianapolis and Christopher Jayson and Phil Farthing of Tampa.

 

Shands Hospitals Pay $3.25 Million in 2nd Part of Florida Whistleblower Settlement

Shands Health Care System has agreed to pay $3.25 million to settle outstanding claims that six of its Florida hospitals submitted improper outpatient billing to the government which resulted in overpayments from Medicaid, Medicare and TRICARE.   This settlement comes on the heels of a $26 million settlement in August of 2013, which resolved additional claims by the same whistleblower also related to improper patient admissions.

James Hoyer Law Firm Partner Christopher Casper served as co-counsel for whistleblower Terry Myers, along with Attorney Marlan Wilbanks, of the Wilbanks and Bridges Law Firm.

Mr. Myers filed the suit in the Middle District of Florida in April of 2008, naming Shands Health Care System and six of its Florida Hospitals:  Shands Alachua General Hospital; Shands Jacksonville Medical Center, Inc.; Shands Teaching Hospital and Clinics, Inc., d/b/a Shands at the University of Florida; Shands at Lakeshore, Inc.; Shands Live Oak; and Shands Starke.

In regards to the remaining allegations following the $26 million settlement, Myers contended that Shands knowingly submitted observation claims to Medicare, Medicaid and TRICARE for certain services and procedures which Shands knew or should have known that physician orders were missing or otherwise deficient for the charges billed.

Myers is the founder and President of YPRO Corporation. The company is a nationwide healthcare consulting firm that was hired by Shands in 2006 and 2007 to conduct audits to determine if Medicare and Medicaid rules were being followed.  Serious billing, coding, and compliance issues were uncovered by the whistleblower’s company and relayed to Shands Corporate Executives and Shands Compliance officers.  Mr. Myers felt compelled to take action by filing the whistleblower suit after Shands failed to correct the problems and self-report the overpayments to the government.

To settle the out-patient/observation claims, Shands will pay the United States $3.14 million for the federal portion of the settlement and an additional $103,668 to the State of Florida for the state portion of the settlement.

The lawsuit was filed under the federal False Claims Act (FCA) and the Florida False Claims Act. The False Claims Act allows private citizens to bring civil actions on behalf of the government in order to recover taxpayer money when fraud is suspected.   If a case is successful, the whistleblower is entitled by law to recover money from the Defendants.