Posts Tagged ‘whistleblower’

James Hoyer Attorney Speaks at Annual Certified Fraud Examiners Conference

James Hoyer Attorney Clark Bolton (center) speaks on panel at 19th Annual ACFE Fraud conference in Tampa Bay.

James Hoyer Attorney Clark Bolton offered unique insight at the 19th annual Association of Certified Fraud Examiners conference in Tampa Bay. As a former fraud examiner turned whistleblower turned False Claims Act attorney, Clark provided a rare look at what it’s like to be an insider exposing fraud and now an attorney litigating fraud against the government.

Clark first came to James Hoyer as a client a decade ago. He was one of four whistleblowers in the $137.5 million WellCare settlement with the Department of Justice. Click here to learn more about Clark’s experience as a whistleblower in his own words.

Following the WellCare settlement, Clark took a long, hard look at his life and decided to make a career change. After more than two decades as a fraud examiner, he committed to becoming an attorney.  In his senior year of law school, he joined James Hoyer as an investigator, and with his trademark  discipline and determination, graduated cum laude.  All the hard work paid off when Clark passed the Florida Bar Exam in April 2018 and became an Associate with the James Hoyer firm. It was an incredible accomplishment after a roller coaster decade that took him from the whistleblower to the lawyer who now helps whistleblowers seeking justice.

Clark shared his story with members of ACFE and explained how important it is for companies to listen to employees when they come forward to voice their concerns internally.  Too often, however, he said “greed” gets in the way and businesses ignore employee concerns.  That’s where Clark and James Hoyer come in. As one of the premiere Whistleblower/False Claims Act firms in the nation, we listen when employees feel they have nowhere else to turn.

If you have knowledge and evidence of fraud against the government, click here to contact us.


James Hoyer Partner Discusses Increasing Pressure on For-Profit Law Schools

James Hoyer partner Jesse Hoyer

For-profit law schools are increasingly facing closer scrutiny.  A recently unsealed whistleblower case against Arizona Summit Law School and its owner InfiLaw raised concerns about how these schools access millions of dollars in federal student aid while producing few graduates who can actually pass the Bar exam. 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.).


Whistleblower says Insurers Bilking Medicare Advantage

A high level whistleblower who worked for UnitedHealth Group says his company and other insurers have been bilking taxpayers by gaming the system to get higher payments.  Benjamin Poehling, a former finance director with United Health, told the New York Times the insurers falsely make it appear that some seniors are sicker than they truly are in order to get more money from the federal government.  Here is an excerpt from the article:

When Medicare was facing an impossible $13 trillion funding gap, Congress opted for a bold fix: It handed over part of the program to insurance companies, expecting them to provide better care at a lower cost. The new program was named Medicare Advantage.

Nearly 15 years later, a third of all Americans who receive some form of Medicare have chosen the insurer-provided version, which, by most accounts, has been a success.

But now a whistle-blower, a former well-placed official at UnitedHealth Group, asserts that the big insurance companies have been systematically bilking Medicare Advantage for years, reaping billions of taxpayer dollars from the program by gaming the payment system.

The Justice Department takes the whistle-blower’s claims so seriously that it has said it intends to sue the whistle-blower’s former employer, UnitedHealth Group, even as it investigates other Medicare Advantage participants. The agency has until the end of Tuesday to take action against UnitedHealth.

In the first interview since his allegations were made public, the whistle-blower, Benjamin Poehling of Bloomington, Minn., described in detail how his company and others like it — in his view — gamed the system: Finance directors like him monitored projects that UnitedHealth had designed to make patients look sicker than they were, by scouring patients’ health records electronically and finding ways to goose the diagnosis codes.

The sicker the patient, the more UnitedHealth was paid by Medicare Advantage — and the bigger the bonuses people earned, including Mr. Poehling.

In February, a federal judge unsealed the lawsuit that Mr. Poehling filed against UnitedHealth and 14 other companies involved in Medicare Advantage.

Click here to read the rest of the article.


$18 Million Settlement: IU Health/HealthNet Whistleblower Case

Dr. Judy Robinson with Tyler & Koger families.

Dr. Judy Robinson with Tyler & Koger families.

A whistleblower suit filed by Dr. Judith Robinson under the False Claims Act has led to an $18 million settlement with two of Indiana’s largest health care providers.  Indiana University Health and HealthNet have agreed to pay $18 million to the federal government and State of Indiana to resolve illegal kickback and false billing claims.  Dr. Robinson, a client of James Hoyer, P.A., filed the whistleblower lawsuit in 2013.

In June, Dr. Robinson met with moms and children harmed during childbirth at IU’s Methodist Hospital. Click here to watch the story by WTHR’s 13 Investigates Reporter Sandra Chapman.

The Whistleblower

Dr. JudithRobinsonPicDr. Judith Robinson is a prominent Indianapolis Ob/Gyn and former employee of both IU Health and HealthNet, a Federally Qualified Health Center (FQHC), which primarily provides services to low income populations.  Her goal was to expose what she believed was substandard care being provided to pregnant women and babies on Medicaid.  This settlement is an important step toward protecting those women and babies.

“I’m grateful this case has shined a light on the care that was provided to low income pregnant women and their babies. I’m hopeful the changes caused by this settlement will help to ensure our community’s most vulnerable patients get the care they need and deserve,” Dr. Robinson said.

Dr. Robinson is represented by Attorney Jillian Estes, a partner at the James Hoyer law firm.

“Dr. Robinson made a real difference because of her courage to come forward,” said Attorney Estes. “Pregnant women and babies in Indianapolis are safer today because of her decision to become a whistleblower.”

The Settlement

The settlement covers three areas, including:

  • Inappropriate billing when Certified Nurse Midwives (CNMs), instead of doctors, cared for high risk pregnant women, in violation of Indiana Medicaid rules;
  • Kickback claims, regarding various financial schemes between IU Health and HealthNet, which improperly induced referrals; and
  • False claims for “wrap around” payments, which are payments made to FQHCs to supplement their care to the poor.

In addition to the $18 million dollars being paid for the settlement, HealthNet has agreed to a Corporate Integrity Agreement with the federal government related to the kickback allegations, which requires HealthNet to restructure and maintain complete independence from IU Health.  HealthNet also signed a separate, side agreement with the State of Indiana, which requires HealthNet to bill only for care to high-risk pregnant women provided by a physician or under a physician’s direction.

“It’s important to note that as part of the settlement, HealthNet has been forced to change its conduct in how it operates and how its CNMs care for high-risk pregnant women,” Attorney Estes said. “We hope these agreements, along with regular monitoring, will ensure that patients will be protected for years to come.”

Certified Nurse Midwife Claims

The suit, filed under the federal and Indiana False Claim Acts, alleged that IU Health and HealthNet violated Indiana Medicaid rules to save money by using CNMs, instead of doctors,  to care for medically high-risk pregnant women.

“Patient care has to come first, not money,” Dr. Robinson said.  “Midwives can provide excellent care to low-risk patients, but when it comes to high-risk pregnancies, the danger for complications requires a doctor’s attention. It’s important to me that these moms and babies get the care they need to keep them safe.”

In Dr. Robinson’s unique position as both Director of Women’s Services for HealthNet and Medical Director of Ob/Gyn Services at Methodist Hospital/IU Health, she became aware of CNM care she believed was putting patients at risk.  Dr. Robinson documented 3 instances of babies suffering permanent neurological damage and 17 “near misses” in just 6 months as a result of care to high-risk patients by CNMs. When her efforts to change the system fell on deaf ears, Dr. Robinson was ostracized and ultimately fired.  She then learned that the billing for CNM care of high-risk patients violated Indiana Medicaid rules and felt compelled to bring her information forward to the government.

Kickback Claims

Anti-kickback laws are essential to discouraging physicians from accepting financial incentives for referring patients, which can lead to unnecessary medical services and increased overall healthcare costs. This whistleblower suit alleged that IU Health paid illegal kickbacks to HealthNet to induce a steady stream of referrals to Methodist Hospital from its FQHC clinics. A variety of financial schemes were at the center of the kickback allegations, including:

  • IU Health providing an ever-increasing line of credit to HealthNet, which ballooned to nearly $14 million, with no strict requirement for payback;
  • IU Health giving HealthNet a sweetheart deal for rent, charging just $1 a year; and
  • IU Health paying to open and subsidize operation of a high-risk maternity clinic for HealthNet, with the understanding that critically ill newborns would be sent to IU’s Methodist Hospital Neonatal Intensive Care Unit, and not to other area NICU’s, as a scheme to make more money for IU Health off of sick babies.

“These hidden financial arrangements and sweetheart deals were not only illegal and costly to Indiana taxpayers, but also inappropriately restricted patient choice on where to get care,” said Attorney Estes. “Now, patients can be referred to the hospital that can best provide care, not just the hospital with financial connections to the clinic.”

Ultrasound Claims

The $18 million settlement also resolves claims from 2005 to 2010 that HealthNet inappropriately received extra payments provided to FQHC’s for physicians to read ultrasounds.  To get the so-called “wrap-around” payments, doctors were required to meet face-to-face with patients, which they did not do.  Additional wrap-around payments for claims made from 2011 to 2015 were also settled, but are still being calculated.  The value of these claims is estimated at $1.4 million.

False Claims Act

The federal False Claims Act provides for private citizens to file suit on behalf of taxpayers when they become aware of fraud against the government.  Whistleblowers receive a portion of the funds returned as a reward for exposing the fraud.

“The False Claims Act is an important tool for the government to fight fraud with the help of whistleblowers,” said Attorney Estes. “It’s very easy for a private citizen who sees wrongs to look the other way, but Dr. Robinson didn’t do that. She did the right thing, and with her help, millions of dollars will be returned to the taxpayers.”

The settlement was reached through a joint effort between Dr. Robinson, her attorneys, and attorneys from the United States Department of Justice and State of Indiana.  Dr. Robinson and her counsel are particularly grateful to Assistant U.S. Attorney Jonathon Bont for his efforts throughout the case in helping to attain a successful resolution.