Tag: Fraud & Abuse

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.

Summary of article from Lathrop GPM, by Jesse A. Berg:

In May 2024, the University of Pittsburgh Medical Center (UPMC) settled a False Claims Act case for $38 million, marking one of the largest settlements in U.S. history for alleged Stark Law violations. The case emphasizes the importance of fair market value compensation in hospital-physician financial arrangements and debunked the idea that a Department of Justice (DOJ) decision not to intervene in an FCA case means the issue is resolved. The case underscores the need for healthcare organizations to ensure their physician compensation practices can withstand increased regulatory scrutiny and comply with Stark Law principles.

Summary of article from D Magazine, by Will Maddox:

Drs. Desi and Deno Barroga have admitted to a healthcare fraud scheme involving false claims for steroid injections that were never provided, defrauding insurers including Blue Cross Blue Shield, Cigna, and United Healthcare. The scheme involved monthly office visits for patients on addictive drugs, where they fraudulently claimed to perform costly treatments. Manipulated medical records and coerced patient statements were used to validate the fraudulent claims, leading to the doctors billing insurance for $45 million and receiving $9 million. Both doctors have a history of disciplinary actions from the Texas Medical Board related to improper prescribing and inadequate record-keeping. The brothers now face a maximum of 10 years in federal prison.

Summary of article from Policy & Medicine, by Thomas Sullivan:

The United States Court of Appeals for the Second Circuit recently ruled that for a defendant to be considered “willful” under the federal Anti-Kickback Statute (AKS), they must be aware that their actions are somehow unlawful. This decision came from a qui tam case against McKesson Corp, which was accused of offering free access to business tools to oncology practices in return for using McKesson as their primary drug supplier. The court upheld the dismissal of the case, finding the evidence insufficient to prove that McKesson acted with wrongful intent. The court’s interpretation of “willful” under the AKS protects those who unintentionally engage in prohibited conduct. Despite this, the case was sent back for review of potential violations of state anti-kickback laws, which may have less stringent requirements.

Summary of article from Dorsey & Whitney LLP, by Nicole Engisch, Seth Goertz, Sarah Malham, Mara Sanders:

The Department of Justice (DOJ) is increasingly using Honest Services Fraud (18 U.S.C. § 1346) to prosecute bribery, kickbacks, and other improper payments in the healthcare industry, in addition to traditional mechanisms like the Anti-Kickback Statute and the Federal False Claims Act. The honest services fraud law is especially useful as it covers areas not reached by the Anti-Kickback Statute, which is limited to federally funded healthcare programs. Recent court cases have upheld convictions based on honest services fraud, indicating its growing relevance in combating healthcare fraud. Therefore, it is crucial for healthcare practitioners and administrators to carefully review payment arrangements and financial interests that intersect with patient service delivery, ensuring full disclosure of relevant financial interests.

Summary of article from Bass, Berry & Sims PLC, by Theresa Androff, Molly Ruberg:

The first quarter of 2024 saw significant False Claims Act (FCA) and civil healthcare fraud settlements in the healthcare industry, despite a recent downward trend. These settlements, worth millions of dollars, were related to alleged kickbacks, medically unnecessary services and equipment, pharmaceutical issues, and Controlled Substances Act violations. Key settlements included New York York-Presbyterian/Brooklyn Methodist Hospital’s $17.3 million for alleged kickbacks, Lincare’s $25.5 million for false claims related to medical equipment, and Endo Health Solutions’ $475.6 million for its opioid marketing schemes. There were also significant settlements related to voluntary self-disclosures, such as Moffitt’s $19.5 million for false claims related to research studies. Additionally, eBay Inc. settled for $59 million, marking the first Controlled Substances Act settlement with an e-commerce company.