Tag: Fraud & Abuse

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.

Summary of article from WFAA, by Ben Sawyers:

North Texas physician’s assistant, Ray Anthony Shoulders, was sentenced to seven years in federal prison on counts of healthcare fraud, after submitting $788,000 in fraudulent medical claims and receiving over $614,000 in Medicare reimbursements. Shoulders was found to be injecting patients with amniotic fluid, a non-FDA approved treatment, under the guise of pain management. He manipulated billing codes to claim reimbursements from Medicare, using codes for an approved product while actually using a non-approved one. The scam, which operated intermittently between August 2020 and October 2021, resulted in significant profits for the clinic. Shoulders was ordered to pay $614,235 in restitution.

Summary of article from Kohn, Kohn & Colapinto LLP, by Geoff Schweller:

In May, the U.S. Department of Justice (DOJ) and U.S. Attorneys’ Offices announced several substantial settlements under the False Claims Act (FCA), resolving qui tam whistleblower lawsuits related to healthcare fraud. The settlements involved cases of kickbacks, billing for unnecessary treatments, and non-compliance with Medicare rules. Prominent cases included a $27 million settlement with Daniel Hurt for alleged Medicare fraud, a $24.3 million settlement with Cape Cod Hospital for non-compliance with Medicare rules, and a $12 million settlement with Innovasis Inc. for alleged kickbacks to surgeons. Other notable settlements involved RiverSpring and Elara Caring, which settled for $10.1 million and $4.2 million respectively. These settlements underscore the importance of whistleblowers in combating healthcare fraud, and highlight the significant financial burden and potential harm caused by fraudulent practices.