Medicaid or Medicare Fraud

A settlement has been reached in a whistleblower class action lawsuit brought against ev3 Inc, formerly Fox Hollow Technologies Inc, who is accused of submitting false claims to Medicare for unnecessary inpatient admissions related to minimally-invasive atherectomy procedures.

According to the settlement the whistleblower will receive $250,000. 

Originally filed by a whistleblower in December 2009, the government's complaint alleged that Fox Hollow, which was acquired by ev3 Inc. in late 2007, knowingly caused 12 hospitals located throughout nine states to submit claims to Medicare for medically unnecessary inpatient stays for certain Medicare beneficiaries undergoing elective atherectomy procedures.  Atherectomy is a minimally-invasive surgical procedure that uses a small cutting device to remove atherosclerosis, or hardening of the arteries, from large blood vessels within the body, and it is intended to open up narrowed coronary arteries to increase blood flow and circulation.  One such device used in atherectomy procedures is the Silver Hawk Plaque Excision System sold by Fox Hollow.  The United States alleged that throughout 2006 and 2007, to increase hospital purchases of the Silver Hawk device, Fox Hollow advised hospitals that they should bill Silver Hawk atherectomy procedures as more expensive inpatient claims, as opposed to less costly outpatient claims.  As a result, certain hospitals allegedly claimed greater reimbursement than they were entitled to for treating Medicare beneficiaries who underwent Silver Hawk atherectomy procedures.

A settlement has been reached in a whistleblower class action lawsuit brought against Good Shepherd Hospice Inc., Good Shepherd Hospice of Mid America Inc., Good Shepherd Hospice, Wichita, L.L.C., Good Shepherd Hospice, Springfield, L.L.C., and Good Shepherd Hospice – Dallas L.L.C. (collectively Good Shepherd), who are accused of submitting false claims for hospice patients who were not terminally ill.

The whistleblower will receive an approximately $680,000 share of the government's recovery.

The whistleblower brought this action in October of 2011 and alleged that Good Shepherd knowingly submitted or caused the submission of false claims for hospice care for patients who were not terminally ill.  Specifically, the United States contended that Good Shepherd engaged in certain business practices that contributed to claims being submitted for patients who did not have a terminal prognosis of six months or less, by pressuring staff to meet admissions and census targets and paying bonuses to staff, including hospice marketers, admissions nurses and executive directors, based on the number of patients enrolled.  The United States further alleged that Good Shepherd hired medical directors based on their ability to refer patients, focusing particularly on medical directors with ties to nursing homes, which were seen as an easy source of patient referrals.  In addition the complaint claims that Good Shepherd failed to properly train staff on the hospice eligibility criteria.

A settlement has been reached to resolve False Claims Act Allegations by ResCare Iowa Inc who is accused of submitting false home healthcare billings to the Medicare and Medicaid programs.

The state of Iowa, which paid part of the Medicaid funds at issue, will receive $2.32 million of the settlement amount. 

The settlement resolves allegations that between 2009 and 2014, ResCare Iowa billed the government for services provided to Medicare and Medicaid patients in Iowa without documenting compliance with these requirements.

A settlement has been reached in a whistleblower class action lawsuit brought against Dr. Michael J. Reinstein, who is accused of receiving illegal kickbacks and benefits totaling nearly $600,000 from two pharmaceutical companies in exchange for regularly prescribing an anti-psychotic drug — clozapine — to his patients. 

The civil settlement resolves a civil action filed against Reinstein by the federal government for accepting payments from pharmaceutical manufacturer Teva Pharmaceuticals USA Inc. and a subsidiary, IVAX LLC, to induce the use of generic clozapine.  The United States alleged that in exchange for these payments, Reinstein prescribed clozapine for Medicare and Medicaid beneficiaries.  The United States also alleged that Reinstein submitted and/or caused to be submitted to both Medicaid and Medicare claims for “pharmacologic management” of those patients for whom he prescribed clozapine.  However, Reinstein allegedly did not engage in meaningful pharmacological management, because his prescribing decisions for his clozapine patients were based on the kickbacks he received rather than his independent medical judgment or the individual needs of his patients.  In March 2014, Teva Pharmaceuticals USA Inc. and IVAX LLC, paid the United States and the state of Illinois $27.6 million to settle allegations that they violated the state and federal False Claims Acts by making payments to Reinstein in return for him prescribing clozapine to his patients.

As set forth in the plea agreement, the payment scheme involving Reinstein began in August 2003, when Reinstein agreed to switch his patients to generic clozapine if IVAX agreed to pay Reinstein $50,000 under a one-year “consulting agreement” and to provide other benefits to Reinstein, in violation of the federal Medicare and Medicaid Anti-Kickback statute.  In addition to direct payments to Reinstein, IVAX allegedly also provided all-expenses paid trips to Miami for Reinstein, his wife and various employees of Reinstein.  Reinstein quickly became the largest prescriber of generic clozapine in the country and prescribed the drug to many elderly patients.  Allegedly, the payments and other forms of remuneration from IVAX and later Teva Pharmaceuticals continued for many years and resulted in the submission of thousands of false claims to the Medicare Part D and Illinois Medicaid programs.

A settlement has been reached resolving Flase Claims Act Allegations of two South Florida medical doctors and their wives, who are accused of accepting sham marketer salaries in exchange for their husbands’ referrals to a home health care company called A Plus Home Health Care Inc.

According to the settlement, Dr. Alan and Lynn Buhler will pay to the United States $1.047 million and Dr. Craig and Cynthia Prokos will pay $90,000.

The United States alleged that, beginning in 2006, A Plus and its owner, Tracy Nemerofsky, engaged in a scheme to increase Medicare referrals in the heavily saturated home health care market in South Florida.  Specifically, the United States alleged that A Plus paid spouses of referring physicians for sham marketing positions in order to induce patient referrals.  Among the spouses allegedly paid by A Plus as part of this scheme were Lynn Buhler and Cynthia Prokos.  The United States alleged that the spouses were required to perform few, if any, of the job duties they were allegedly hired for and instead, the spouses’ salaries were intended as an inducement for the husband physicians to refer their Medicare patients to A Plus.  The United States also alleged that Alan Buhler received medical director payments as part of A Plus’s scheme to obtain his referrals and he attempted to hide those payments from the United States. 

The United States previously settled with A Plus, Tracy Nemerofsky and five other couples that allegedly accepted payments from A Plus.

A settlement has been reached resolving False Claims Act allegations by BioTelemetry Inc that its subsidiary, CardioNet, overbilled Medicare and other federal health programs for Mobile Cardiac Outpatient Telemetry (MCOT) services when those services were not reasonable or medically necessary.

The government alleges that CardioNet was aware that MCOT services were not eligible for Medicare reimbursement when provided to patients who had experienced only mild or moderate heart palpitations, since less expensive monitors could effectively collect data about those patients’ conditions.  CardioNet allegedly submitted claims to Medicare anyway for those patients containing the billing code for the more expensive MCOT services along with an inaccurate diagnostic code that misrepresented the true condition of the patients and their need for MCOT services.

A settlement has been reached in a whistleblower class action lawsuit brought against Family Dermatology P.C. who is accused of engaging in improper financial relationships with a number of its employed physicians.

The whistleblowers will collectively receive more than $584,000 from the government's recovery.

The government's case stemmed for a series of whistleblower lawsuit, the first of which was filed in July of 2011.  The cases alleged that Family Dermatology’s financial relationships with a number of these physicians did not comply with the requirements of the Stark Statute, and that Family Dermatology improperly billed Medicare for dermatopathology analyses performed by Nelson Dermatopathology on specimens that were sent to the laboratory by these employed physicians.

A settlement has been reached to Resolve False Claims Act Allegations with Medical Center of Central Georgia, which changed its name to Navicent Health in September 2014. They are accused of billing Medicare for more expensive inpatient services that should have been billed as less costly outpatient or observation services.

The government contends that from 2004 through 2008, MCCG violated the False Claims Act by knowingly charging Medicare for medically unnecessary inpatient admissions when the care provided should have been billed as less costly outpatient or observation services.

A settlement has been reached in a whistleblower class action lawsuit brought against PharMerica Corporation who is accused of violating the Controlled Substances Act by dispensing Schedule II controlled drugs without a valid prescription and violating the False Claims Act by submitting false claims to Medicare for these improperly dispensed drugs, 

$4.3 million is the whistleblower's share of the settlement.

The original whistleblower case was filed in 2009 and alleged that PharMerica pharmacies operating across the country routinely dispensed Schedule II controlled drugs in non-emergency situations without first obtaining a written prescription from a treating physician.  According to the complaint, PharMerica’s actions violated the Controlled Substances Act by enabling nursing home staff to order narcotics, and pharmacists to dispense them, without confirming that a physician had made a medical judgment as to whether the narcotics were necessary and should be administered to the resident.

The government’s complaint also alleged that PharMerica violated the False Claims Act by knowingly causing the submission of false claims to Medicare Part D for improperly dispensed Schedule II drugs.  

A settlement has been reached in a whistleblower class action lawsuit brought against Garden State Cardiovascular Specialists P.C. who is accused of falsely billing federal health care programs for tests that were not medically necessary.

The whistleblower will receive more than $648,000 as part of the settlement.

Filed in 2010, the whistleblower case alleged that Garden State submitted claims to Medicare for various cardiology diagnostic tests and procedures, including stress tests, cardiac catheterizations and external counterpulsation, which were not medically necessary.