Posts Tagged ‘medicare fraud’

James Hoyer Prime Hospital Case Takes Major Step Forward

Prime Whistleblower
Karin-1-medium

Karin Berntsen – James Hoyer Client

The whistleblower case filed against Prime Healthcare by James Hoyer client Karin Berntsen has cleared a major hurdle.  The defendant’s Motion to Dismiss the case was denied in its entirety.  Judge Patrick Walsh of the U.S. District Court for the Central District of California wrote:

Based on these allegations, the Court is satisfied that Berntsen has stated an FCA (False Claims Act) claim with sufficient particularity as against all Defendants. Having carefully reviewed the FAC, the Court finds that it includes the who, what, when, where, and how of the alleged fraud.

The San Jose Mercury News wrote about the decision in an article, Controversial hospital chain owner poised to expand empire to Bay Area, about the hospital chain’s rapid expansion.  The article outlined the allegations in Berntsen’s complaint against Prime Healthcare:

Karin Berntsen, who gathered information during meetings with Reddy, alleges in the civil suit that Prime hospitals admit patients when medically unnecessary; “upcode” — that is, falsify patient records and billing codes to increase reimbursement; and, in order to make more money, often refuse to discharge patients or transfer them to another hospital.

The article goes on to further explain the allegations:

Berntsen is a veteran registered nurse, author of a book on patient safety and is currently the director of performance improvement at Alvarado Hospital in San Diego. In her suit, she accuses Reddy, as well as the hospital’s CEO and 14 of Prime’s California hospitals, of bilking the federal government of at least $50 million.

Click here to read the entire article in the San Jose Mercury News.

 

Amedisys Home Health Agrees to Pay $150 Million to Resolve Whistleblower Case

The Department of Justice announced today that Amedisys Inc. and its affiliates have agreed to pay $150 million to the federal government to resolve allegations that they violated the False Claims Act by submitting false home healthcare billings to the Medicare program. Amedisys, a Louisiana-based for-profit company, is one of the nation’s largest providers of home health services and operates in 37 states, the District of Columbia and Puerto Rico.

“It is critical that scarce Medicare home health dollars flow only to those who provide qualified services,” said Stuart F. Delery, Assistant Attorney General for the Civil Division. “This settlement demonstrates the department’s commitment to ensuring that home health providers, like other providers, comply with the rules and don’t misuse taxpayer dollars.”

The settlement announced today resolves allegations that, between 2008 and 2010, certain Amedisys offices improperly billed Medicare for ineligible patients and services. Amedisys allegedly billed Medicare for nursing and therapy services that were medically unnecessary or provided to patients who were not homebound, and otherwise misrepresented patients’ conditions to increase its Medicare payments. These billing violations were the alleged result of management pressure on nurses and therapists to provide care based on the financial benefits to Amedisys, rather than the needs of patients.

Additionally, this settlement resolves certain allegations that Amedisys maintained improper financial relationships with referring physicians. The Anti-Kickback Statute and the Stark Statute restrict the financial relationships that home healthcare providers may have with doctors who refer patients to them. The United States alleged that Amedisys’ financial relationship with a private oncology practice in Georgia – whereby Amedisys employees provided patient care coordination services to the oncology practice at below-market prices – violated statutory requirements.

“Combating Medicare fraud and overbilling is a priority for my office, other components of the Department of Justice, and United States Attorneys’ Offices across the country,” said Zane David Memeger, United States Attorney for the Eastern District of Pennsylvania. “We have recovered billions of dollars in federal health care funds from schemes such as the one alleged in this case. Those are health care dollars that should be spent on legitimate medical needs.”

“Home health services are a large and growing part of our federal health care system,” said Sally Quillian Yates, United States Attorney for the Northern District of Georgia. “Health care dollars must be reserved to pay for services needed by patients, not to enrich providers who are bilking the system.”

“Amedisys made false Medicare claims, depriving the American taxpayer of millions of dollars and unlawfully enriching Amedisys,” said Joyce White Vance, U.S. Attorney for the Northern District of Alabama. “The vigorous enforcement work by assistant U.S. attorneys in my office, along with their colleagues in North Georgia, Eastern Pennsylvania, Eastern Kentucky and the Civil Division of the Justice Department, has secured the return of $150 million to the taxpayers and stands as a warning to future wrongdoers that we will aggressively pursue them.”

“This settlement represents a significant recovery of public funds and an important victory for the taxpayers,” said Kerry B. Harvey, United States Attorney for the Eastern District of Kentucky. “Fighting health care fraud and recovering tax payer dollars that fund our vital health care programs is one of the highest priorities for our district.”

Amedisys also agreed to be bound by the terms of a Corporate Integrity Agreement with the Department of Health and Human Services – Office of Inspector General that requires the companies to implement compliance measures designed to avoid or promptly detect conduct similar to that which gave rise to the settlement.

“Improper financial relationships and false billing, as alleged in this case, can shortchange taxpayers and patients,” said Daniel R. Levinson, Inspector General for the U.S. Department of Health and Human Services. “Our compliance agreement with Amedisys contains strong monitoring and reporting provisions to help ensure that people in Federal health programs will be protected.”

This settlement resolves seven lawsuits pending against Amedisys in federal court – six in the Eastern District of Pennsylvania and one in the Northern District of Georgia – that were filed under the qui tam, or whistleblower, provisions of the False Claims Act, which allow private citizens to bring civil actions on behalf of the United States and share in any recovery. As part of today’s settlement, the whistleblowers – primarily former Amedisys employees – will collectively split over $26 million.

This settlement illustrates the government’s emphasis on combating health care fraud and marks another achievement for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced in May 2009 by Attorney General Eric Holder and Secretary of Health and Human Services Kathleen Sebelius. The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation. One of the most powerful tools in this effort is the False Claims Act. Since January 2009, the Justice Department has recovered a total of more than $19.2 billion through False Claims Act cases, with more than $13.6 billion of that amount recovered in cases involving fraud against federal health care

 

Vermont Introducing Legislation to Add State False Claims Act

MONTPELIER — At the suggestion of the Vermont Attorney General’s Office, Senate lawmakers will introduce false claims legislation next week targeted at preventing fraud in the state’s health care system.

“As we’re moving to a world where the state’s role in health care is greatly expanded, ensuring that Vermont has the tools to protect its money from waste fraud and abuse is critically important,” said John Treadwell, chief of the criminal division in the Attorney General’s Office.

Vermont’s planned universal health care program would make state government the primary payer of nearly all medical claims, hence the aphorism single-payer.

The legislation will mimic the federal False Claims Act, which dates back to the Civil War and was designed to punish unscrupulous vendors for selling the Union faulty weapons or other equipment.

Passing a Vermont false claims act targeted at fraud in the health care system, specifically Medicaid – which receives federal matching dollars but is a large expense to the state – will have immediate benefits, Treadwell said.

If states pass their own federally compliant false claims acts, they can keep a larger percentage of the money recovered from resulting lawsuits and settlements.

Click here to read more in the Brattleboro Reformer.

 

Halifax Hospital Partially Settles Whistleblower Case for $85 Million

Halifax Hospital agreed to pay a record-setting $85 million to settle part of a whistleblower case pending against the company.  The James Hoyer Law Firm serves as local counsel in the case, along side the Wilbanks & Bridges Law Firm in Atlanta.  As reported in the Orlando Sentinel, the lawsuit alleges Medicare fraud and more than a decade of illegal kickbacks to doctors.

The “agreement in principle” requires that Halifax pay the settlement amount over a period of five years.

In addition, Halifax must agree to a corporate integrity and compliance program “to make sure that something like this doesn’t happen in the future,” said the court transcript.

The lawsuit was first filed in 2009 by Halifax Health employee Elin Baklid-Kunz, a former compliance officer for the 678-bed Daytona Beach hospital, where she is still employed.

The suit was filed under the federal False Claims Act which allows private citizens to file suit on behalf of taxpayers, when fraud against the government is suspected.  As a result, the bulk of the $85 million will be returned to the public coffers.  Baklid-Kunz will receive 15 percent to 25 percent of the award, for bringing the fraud to the government’s attention, as provided under the qui tam provision of the False Claims Act.

The second part of this case is slated to go to trial in July.  Those charges involve allegations that Halifax Hospital inappropriately admitted patients to their emergency room and then billed Medicare and Medicaid for their care.  That portion of the case could result in damages and penalties of up to $400 million.

UPDATE:  Halifax agreed to settle the second portion of the case for $1 million in July of 2014.

Click on the video below to watch a report by WFTV in Orlando about the settlement.

 

Orlando Area Hospice Pays $3 Million to Settle Medicare Fraud Charges

Hospice of the Comforter Inc. (HOTCI) was accused of billing Medicare for patients who were not terminally ill, according to the Department of Justice.   The company has agreed to pay $3 million to resolve the allegations.  The government says evidence showed HOTCI violated the False Claims Act by submitting false claims to the Medicare program for hospice services provided to patients who were not eligible for the Medicare hospice benefit. HOTCI is headquartered in Altamonte Springs, Fla., and provides hospice services to patients residing in Seminole, Osceola and Orange counties in Florida.

“This settlement is a result of the Justice Department’s continuing efforts to prevent the abuse of the taxpayer-funded Medicare hospice program, which is intended to provide comfort and care to terminally ill persons during the last six months of their lives,” said Assistant Attorney General for the Civil Division Stuart F. Delery. “We will pursue those who seek to misuse this important benefit for their own enrichment.”

The government alleged that between December 2005 and December 2010, HOTCI engaged in practices that resulted in billing Medicare for patients who were not terminally ill. Specifically, HOTCI allegedly directed its staff to admit all referred patients without regard to whether they were eligible for the Medicare hospice benefit, falsified medical records to make it appear that certain patients were eligible for the benefit when they were not, employed field nurses without hospice training, established procedures to limit physicians’ roles in assessing patients’ terminal status and delayed discharging patients when they became ineligible for the benefit.

As part of this settlement, HOTCI has agreed to enter into a Corporate Integrity Agreement with the Inspector General of the Department of Health and Human Services that provides for procedures and reviews to be put in place to promptly detect and prevent future conduct similar to that which gave rise to the settlement. In addition, HOTCI’s former Chief Executive Officer Robert Wilson has agreed to a three-year, voluntary exclusion from Medicare, Medicaid and other federal health care programs.

“This settlement represents a fair and appropriate resolution of this troubling matter,” said Acting U.S. Attorney for the Middle District of Florida A. Lee Bentley III. “Hospice providers in our district should be on notice that our office will do what it takes to protect our citizens from this kind of misconduct.”

“Hospice care is a sacred trust from which no provider should fraudulently profit,” said Inspector General of the U.S. Department of Health and Human Services Daniel R. Levinson. “Claiming tax dollars for people who are not terminally ill  and therefore ineligible for hospice care cannot be tolerated.”

This settlement illustrates the government’s emphasis on combating health care fraud and marks another achievement for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced in May 2009 by Attorney General Eric Holder and Health and Human Services Secretary Kathleen Sebelius. The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation. One of the most powerful tools in this effort is the False Claims Act. Since January 2009, the Justice Department has recovered a total of more than $16.7 billion through False Claims Act cases, with more than $11.9 billion of that amount recovered in cases involving fraud against federal health care programs.

The allegations settled today arose from a lawsuit filed by a former HOTCI employee, Douglas Stone, under the qui tam, or whistleblower, provisions of the False Claims Act. Under the act, private citizens can bring suit on behalf of the government for false claims and share in any recovery. Stone’s share of the recovery has not been determined.

 Click here to read more about the settlement on the DOJ website.