Tag: Fraud & Abuse

Summary of article from King & Spalding, by Doug Comin:

On July 8, 2024, the Office of Inspector General (OIG) updated its Frequently Asked Questions regarding fraud and abuse authorities, adding four new questions and answers. The updates address the legality and conditions under which hospitals may waive cost-sharing charges for patients under financial assistance or charity care policies without violating the federal anti-kickback statute (AKS) or the Civil Monetary Penalty Law (CMP Law). OIG clarifies that waivers for uninsured or commercially insured patients generally do not violate these laws, but waivers for Federal health care program enrollees could be problematic unless they fall under specific safe harbors or exceptions. Hospitals can inform patients about financial assistance policies, provided such information is not advertised or solicited in a manner that could be construed as inducement. Additionally, offering free care to uninsured or commercially insured patients and advertising this care does not violate AKS or CMP Law. Finally, hospitals may disseminate information about financial assistance policies through various channels, ensuring the communication is compliant and low-risk under the relevant statutes. The full FAQs can be accessed on the OIG website.

Summary of article from MSN, by Brian New:

CBS News Texas’ investigation into alleged Medicare fraud uncovered over $200 million in fraudulent activities linked to several companies, prompting numerous viewers to report their own experiences with Medicare fraud. A subsequent report identified 11 additional Texas-based medical supply companies potentially involved in fraudulent practices. Many of these companies, such as Lone Star Medlab Laboratories and Peak Health Diagnostics, were found to have vacated their offices and disconnected their contact numbers. Aids for Recovery faced numerous complaints for fraudulent billing and had abandoned their office, leaving behind unopened Medicare correspondence. The Centers for Medicare & Medicaid Services (CMS) confirmed ongoing investigations into these companies, suspected of nearly $3 billion in fraudulent catheter billing.

Summary of article from Bass, Berry & Sims PLC, by Latazia Carter, Scott Gallisdorfer:

In Q2 2024, the Department of Justice announced significant False Claims Act settlements, highlighting ongoing enforcement in areas such as unlawful kickbacks, improper billing, and subcontracting violations. Notable settlements included a $27.9 million agreement with a laboratory owner for fraudulent cancer genomic tests and a $12 million settlement with Innovasis Inc. for paying kickbacks to spine surgeons. Cape Cod Hospital and a chronic disease management provider, facing Medicare billing violations, each entered into Corporate Integrity Agreements (CIAs) and paid $24.3 million and $14.9 million, respectively. Additionally, CityMD resolved COVID-19 testing fraud allegations with a $12 million settlement, and Sikorsky Services Inc. and Derco Aerospace Inc. paid $70 million for unlawful subcontracting practices in Navy procurement. These cases underscore the importance of compliance for entities engaged in government contracts and healthcare services.

Summary of article from Mintz, by Laurence J. Freedman, Laura E. Martin:

The Supreme Court has the opportunity to clarify the definition of “willfulness” under the Anti-Kickback Statute (AKS) in a case involving McKesson Corporation. The Second Circuit upheld the dismissal of a False Claims Act (FCA) case, ruling that “willfulness” under the AKS requires the defendant to know their conduct is unlawful. The petitioner, Adam Hart, argues that this interpretation is too stringent and seeks Supreme Court review to resolve a circuit split on the issue. The outcome could significantly impact the Department of Justice and relators’ ability to prove AKS violations as predicates for FCA claims. The case has attracted significant interest from various industry and legal groups, anticipating potential Supreme Court involvement.

Summary of article from U.S. Attorney’s Office, Southern District of Texas:

Baylor St. Luke’s Medical Center, Baylor College of Medicine, and Surgical Associates of Texas have agreed to a $15 million settlement to resolve allegations of improper concurrent billing for heart surgeries, violating Medicare regulations and informed consent rules. The investigation, initiated by a whistleblower complaint in 2019, revealed that surgeons Dr. Joseph Coselli, Dr. Joseph Lamelas, and Dr. David Ott allegedly ran multiple operating rooms simultaneously, improperly delegating critical tasks to unqualified residents and falsifying records. This practice, which occurred from June 2013 to December 2020, compromised patient safety and violated Medicare’s requirements for surgeon presence. The settlement, the largest of its kind, underscores the importance of adherence to medical regulations and accountability in healthcare. The whistleblower will receive over $3 million from the settlement.

Summary of article from D Magazine, by Will Maddox:

Dr. Rodney Sosa, a Southlake physician, was convicted of defrauding the United States government and sentenced to 46 months in federal custody. The conviction was related to a telemedicine scheme involving unnecessary medical equipment and testing, for which he submitted $1.4 million worth of claims. His medical license was revoked in April 2024, following his sentencing in March. Sosa also allegedly practiced as a plastic surgeon at Ver Halen Aesthetics, despite his certification being in internal medicine. Investigations into Sosa’s activities at Ver Halen Aesthetics are ongoing.