When corrupt Hospitals, Health Care Providers, Nursing Homes, or Hospice Providers commit Medicare fraud, it is up to hospital administrators, benefit administrators, medical billing specialists, medical coding specialists, accountants, benefit specialists, facility coding supervisors, and other American Heroes to blow the whistle on Medicare Fraud and file False Claims Act Lawsuits, Qui Tam Claims, and Whistleblower lawsuits to help recover the millions of dollars that are being fraudulently stolen from Medicare, Medicaid, the United States or State Governments.  

If you are aware of a hospital or large health care company that is defrauding Medicare, the United States Government or a State Government out of millions or billions of dollars, contact Hospital Administrator Whistleblower Medicare Fraud and Hospice Fraud Lawyer, Jason S. Coomer, via e-mail or via our online submission form for a free review of a potential qui tam Medicare Fraud Whistleblower Lawsuit. 

Health Care Fraud, Hospital Billing Fraud, and Medicare Fraud Law Suits (Qui Tam Hospital Administrator Whistleblower Claims)

Law enforcement authorities estimate that health-care fraud costs taxpayers between $60 billion and $100 billion each year.  Through Health Care Fraud, Hospital Billing & Upcoding Fraud, Hospice Fraud, Off-Label Marketing Fraud, and Medicare Fraud Lawsuits billions of dollars have been recovered from individuals and organizations that have committed health care fraud on the United States Government and State Governments. 

Health care fraud costs United States Tax Payers large amounts of money through Medicare, Medicaid, and other government health care programs.  A critical aspect of the Health Care Fraud problem is that Medicare, the health program for the elderly and the disabled, automatically pays the vast majority of the bills it receives from companies that possess federally issued supplier numbers. Computer and audit systems now in place to detect problems generally focus on over billing and unorthodox medical treatment rather than fraud creating a need for Hospital Administrator Whistleblowers to step forward and blow the whistle on fraudulent medical billing.

Additionally, the United States Government has increased efforts to crack down on Medicare fraud scams including upcoding, double billing, fraudulent medical billing, illegal kickbacks, and

Below are some recent news stories from the United States Government on Medicare and health care fraud where fraudulent hospital administrators, hospitals, and health care providers have been caught committing health fraud and/or Medicare fraud.  For more stories on Medicare fraud crackdowns, please go to the United States Department of Justice press releases.

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Massachusetts Hospital Agrees to Pay U.S. $2.79 Million to Resolve False Claims Act Allegations

"WASHINGTON – Mercy Hospital Inc. (d/b/a Mercy Medical Center) of Springfield, Mass., has agreed to pay the United States $2,799,462 to settle claims that it violated the False Claims Act between 2005 and 2006 by failing to provide, or failing to document that it provided, the minimum number of hours of rehabilitation therapy required under Medicare guidelines".

"Under Medicare, inpatient rehabilitation hospitals must provide a minimum amount of rehabilitative therapy to their patients. In June 2007, Mercy disclosed to the Department of Health and Human Services Office of Inspector General that it could not demonstrate that it had provided the required level of therapy. The settlement announced today resulted from the company’s disclosure."

"This settlement demonstrates the Justice Department’s commitment to ensuring that Medicare patients get all of the care that Medicare pays for," said Tony West, Assistant Attorney General for the Civil Division of the Department of Justice. "As this settlement shows, those who come forward to disclose their violations and cooperate with the government will be dealt with fairly."

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Brookhaven Memorial Hospital Medical Center in New York to Pay U.S. $2.92 Million to Resolve Fraud Allegations

"WASHINGTON – Brookhaven Memorial Hospital Medical Center, a Long Island, N.Y.-based hospital, has agreed to pay $2.92 million, plus interest, to settle allegations that the hospital defrauded Medicare".

"The government alleged that the hospital fraudulently inflated its charges to Medicare patients to obtain enhanced reimbursement from the federal health care program. In addition to its standard payment system, Medicare provides supplemental reimbursement, called "outlier payments," to hospitals and other health care providers in cases where the cost of care is unusually high. Congress enacted the supplemental outlier payments system to ensure that hospitals possess the incentive to treat inpatients whose care requires unusually high costs. The lawsuit alleged that the hospital inflated its charges to obtain supplemental outlier payments for cases that were not extraordinarily costly and for which outlier payments should not have been paid."

"Conduct like that alleged here drives up the costs of health care for all of us," said Tony West, Assistant Attorney General for the Justice Department’s Civil Division. "The resolution announced today is the most recent in a series of settlements that illustrates the Justice Department's continued commitment to protecting the Medicare Trust Fund from hospitals that knowingly charge more than the law allows."

"The suit was originally filed in the U.S. District Court for the District of New Jersey by a whistleblower, Tony Kite, in 2005. The United States intervened in the suit in November 2009. Mr. Kite brought his suit under the whistleblower provisions of the False Claims Act, which permit private citizens with knowledge of fraud against the government to bring a lawsuit on behalf of the United States and to share in any recovery. Under the civil settlement announced today, Mr. Kite will receive roughly $613,000, plus interest, out of the settlement proceeds. "

"This office is determined to root out any conduct that threatens to undermine the integrity of the federal health care programs," said Paul J. Fishman, U.S. Attorney for the District of New Jersey.

"The settlement is the result of a coordinated effort by the Commercial Litigation Branch of the Justice Department’s Civil Division; the U.S. Attorney’s Office for the District of New Jersey, Affirmative Civil Enforcement Unit; the Department of Health and Human Services, Office of Inspector General, and the Centers for Medicare and Medicaid Services; and the Federal Bureau of Investigation."

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Two Atlanta-Based Nursing Home Chains and Their Principals Pay $14 Million to Settle False Claims Act Case

"WASHINGTON – Atlanta-based Mariner Health Care Inc. and SavaSeniorCare Administrative Services LLC, as well as their principals, Leonard Grunstein, Murray Forman and Rubin Schron, have agreed to pay the United States and several states $14 million".

"This settlement arises from allegations of the United States that the defendants solicited kickback payments from Omnicare, the nation’s largest pharmacy that specializes in dispensing drugs to nursing home patients, in exchange for agreements by Mariner and Sava to continue using Omnicare’s pharmacy services for 15 years."

"In a complaint filed in March 2009 and unsealed in November 2009, the United States alleged that Omnicare, Mariner, Sava, Grunstein, Forman and Schron conspired to arrange for Omnicare to pay Mariner and Sava $50 million in exchange for the right to continue providing pharmacy services to the nursing homes, which together constituted one of Omnicare’s largest customers. The parties allegedly attempted to disguise the $50 million kickback as a payment to acquire a small Mariner business unit that had only two employees and was worth far less than $50 million. According to the complaint, Omnicare paid $40 million of this amount prior to actually acquiring the Mariner business unit and, at the same time, Omnicare obtained new 15-year pharmacy contracts from Mariner and from Sava, a new nursing home chain that Grunstein and Forman created from the Mariner chain. The complaint alleged that Grunstein and Forman illegally tied the new pharmacy contracts to Omnicare’s agreement to purchase the small Mariner business unit, and that the total $50 million purchase price for the business unit actually was a kickback by Omnicare to keep the future business of Mariner and Sava."

"Approximately $7.84 million of the settlement proceeds will go to the United States, while $6.16 million has been allocated to certain state Medicaid programs. In November 2009, the United States, numerous states and Omnicare entered into a $98 million settlement agreement that, among other things, resolved Omnicare’s civil liability under the False Claims Act for allegedly paying a kickback to Mariner and Sava."

"The government’s complaint further alleged that, in 2006, after the government issued subpoenas concerning the transaction, the individual defendants created backdated documents in a further attempt to hide the kickback."

"Nursing home residents and their families are entitled to make health care decisions free from the distortions caused by illegal kickback schemes," said Tony West, Assistant Attorney General for the Justice Department’s Civil Division.

"This case reflects the government’s continuing efforts to pursue those who scheme to hide illegal payments that can affect the way drugs and other services are delivered to nursing home residents, an especially vulnerable patient population," said Carmen M. Ortiz, U.S. Attorney for the District of Massachusetts."

"Kickbacks in all forms are insidious because they distort medical decisions affecting Medicare and Medicaid beneficiaries," said Daniel R. Levinson, Inspector General of the Department of Health and Human Services Office of Inspector General. "We will vigilantly scrutinize attempts to disguise kickbacks as legitimate business transactions and work to hold payers and recipients of kickbacks accountable."

"As part of the settlement, Mariner has entered into a corporate integrity agreement with the Office of Inspector General of the Department of Health and Human Services (OIG-HHS). This agreement provides for Mariner to put in place procedures and reviews to avoid and promptly detect conduct similar to that which gave rise to this matter. At the same time, OIG-HHS has reserved its rights to seek exclusions of Sava, Grunstein, Forman and/or Schron from participation in Medicare, Medicaid and all other federal health care programs."

"The settlement resolves a whistleblower action, United States ex rel. Resnick v. Omnicare, Inc., et al., No. 06-10149-RGS (D. Mass.), filed under the qui tam provisions of the False Claims Act."

"The case was handled by the Justice Department’s Civil Division, the U.S. Attorney for the District of Massachusetts, the Office of Inspector General of the Department of Health and Human Services, and the Federal Bureau of Investigation."

"This settlement is part of the government’s emphasis on combating health care fraud. One of the most powerful tools in that effort is the False Claims Act, which the Justice Department has used to recover approximately $2.2 billion since January 2009 in cases involving fraud against federal health care programs. The Justice Department’s total recoveries in False Claims Act cases since January 2009 have topped $3 billion."

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Former Tustin Hospital Executive Agrees to Plead Guilty to Paying Kickbacks in ‘Skid Row’ Health Care Fraud Plot

LOS ANGELES—The former chief financial officer of Tustin Hospital and Medical Center agreed in court papers filed today to plead guilty to paying illegal kickbacks for patients who were recruited from the “Skid Row” area of Los Angeles.

In a plea agreement filed in United States District Court, Vincent Rubio 49, of Los Angeles, admitted paying illegal kickbacks to “marketers” who recruited homeless persons from Los Angeles’ Skid Row and had them transported to Tustin Hospital.

In addition to the healthcare fraud charge, Rubio admitted that he failed to report the payments he received from one of the marketers on his federal tax returns.

Rubio specifically admitted to participating in a scheme to pay Estill Mitts, who operated a center on Skid Row that recruited homeless people to receive unnecessary health services, and others to refer homeless Medicare and Medi-Cal beneficiaries to Tustin Hospital for in-patient hospital stays. As part of the scheme, Tustin Hospital entered into sham “consulting” contracts intended to conceal the illegal kickbacks. Tustin billed Medicare and Medi-Cal for in-patient services provided to the recruited homeless beneficiaries, including those for whom in-patient hospitalization was not medically necessary.

Tustin is a subsidiary of Pacific Health Corporation, which also owns Los Angeles Metropolitan Medical Center, Anaheim General Hospital and Bellflower Medical Center.

Rubio is the fifth person to be charged in relation to an ongoing investigation into health care fraud related to Skid Row residents. Mitts, 65, of Los Angeles, pleaded guilty in September 2008 to conspiracy to commit health care fraud, money laundering and tax evasion, and he is scheduled to be sentenced on June 21. Rudra Sabaratnam, 65, one of the owners of City of Angels Hospital in Los Angeles pleaded guilty in December 2008 to paying illegal kickbacks for patient referrals, and he is scheduled to be sentenced on April 5. Dante Nicholson, 52, senior vice president of City of Angels, pleaded guilty in March 2009 to paying illegal kickbacks for patient referrals, and he is scheduled to be sentenced on June 14. Robert Bourseau, co-owner of City of Angels, pleaded guilty in June 2009 to paying illegal kickbacks, and he is scheduled to be sentenced on February 22. United States District Judge George H. King is presiding over all of the Skid Row cases.

The three charges to which Rubio has agreed to plead guilty carry a statutory maximum penalty of 11 years in federal prison. Rubio is expected to make his initial appearance in United States District Court on March 1.

The ongoing investigation into healthcare fraud related to the recruitment of Skid Row denizens is being conducted by the U.S. Department of Health and Human Services, Office of Inspector General; the Federal Bureau of Investigation; IRS-Criminal Investigation; the California Department of Justice’s Bureau of Medi-Cal Fraud and Elder Abuse; and the Health and Law Enforcement Team (HALT), a multi-agency task force which is operated by the Los Angeles County Health Department.

Anyone with information that could assist the ongoing investigation is encouraged to contact investigators with the Department of Health and Human Services by calling 1-800-HHS-TIPS, or e-mailing HHSTips@oig.hhs.gov.

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FORMER PURCHASING OFFICIAL AT A NEW YORK CITY HOSPITAL INDICTED FOR BID RIGGING AND FRAUD CONSPIRACY

"WASHINGTON — A New York City federal grand jury returned an indictment against a former Mount Sinai Medical Center and School of Medicine purchasing official today for participating in bid-rigging and fraud conspiracies related to contracts for work performed at Mount Sinai, the Department of Justice announced."

"The three-count indictment returned today in U.S. District Court in New York City, charges Mario Perciavalle, a former purchasing official at Mount Sinai, with engaging in a conspiracy to rig bids on Mount Sinai contracts for maintenance and insulation services between June 2004 and September 2005. Perciavalle and his co-conspirators took steps to create the appearance that Mount Sinai was awarding contracts based on competition, when, in fact, they submitted, or caused to be submitted, intentionally high, non-competitive bids to Mount Sinai on these contracts."

"The indictment further charges that between March 2003 and September 2005, Perciavalle and a co-conspirator engaged in a mail fraud conspiracy, in which Perciavalle awarded work at Mount Sinai to that co-conspirator's company at the same time he was asking for and receiving cash kickbacks from the co-conspirator. Perciavalle is also charged with mail fraud as a result of payments mailed by Mount Sinai to Percivalle's co-conspirator for work done on the rigged contracts."

"The bid-rigging violation that Perciavalle is charged with carries a maximum penalty of 10 years in prison and a $1 million fine. The fraud conspiracy that Perciavalle is charged with carries a maximum penalty of 20 years in prison and a $1 million fine. The maximum fine for both of the charges may be increased to twice the gain derived from the crime or twice the loss suffered by the victim of the crime, if either of those amounts is greater than the statutory maximum fine. "

"The charges announced today resulted from an ongoing federal antitrust investigation of bid rigging, fraud, bribery and tax-related offenses relating to construction, maintenance and service contracts administered by the Engineering Department of Mount Sinai and the Facilities Operations Department and the Engineering Department at New York Presbyterian Hospital (NYPH). To date, eight individuals and three companies have pleaded guilty to charges arising out of this ongoing investigation. Additionally, two individuals were charged in a three-count indictment unsealed on March 31, 2010, for participating in bid-rigging and tax fraud conspiracies related to contracts at NYPH. The investigation is being conducted by the Antitrust Division's New York Field Office, the FBI and the Internal Revenue Service Criminal Investigation's New York Field Office."

"Anyone with information concerning bid rigging, bribery, tax offenses or fraud related to contracts administered by the Facilities Operation Department at NYPH or the Engineering Departments at Mount Sinai or NYPH should contact the Antitrust Division's New York Field Office at 212-264-9308 or the FBI's New York Division at 212-384-1000 or visit http://www.justice.gov/atr/contact/newcase.htm."

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New Jersey Hospital to Pay $6.35 Million to Resolve Allegations of Inflating Charges to Obtain Higher Medicare Reimbursement

"WASHINGTON—Robert Wood Johnson University Hospital Hamilton, a New Jersey-based hospital, has agreed to pay $6.35 million to settle allegations that the hospital defrauded Medicare, the Justice Department announced. Two lawsuits filed against the Hamilton, N.J., facility alleged that the hospital fraudulently inflated its charges to Medicare patients to obtain larger reimbursements from the federal health care program."

"In addition to its standard payment system, Medicare provides supplemental reimbursement, called “outlier payments,” to hospitals and other health care providers in cases where the cost of care is unusually high. Congress enacted the supplemental outlier payments system to ensure that hospitals have the incentive to treat inpatients whose care requires unusually high costs. The two lawsuits filed against Robert Wood Johnson University Hospital Hamilton alleged that the hospital inflated its charges to obtain supplemental outlier payments for cases that were not extraordinarily costly and for which outlier payments should not have been paid. The United States intervened in both lawsuits in January 2008."

“Taxpayer dollars should go towards quality health care, not wasted on fraud and abuse,” said Tony West, Assistant Attorney General for the Civil Division of the Department of Justice. “As the settlement announced today demonstrates, the Justice Department is committed to pursuing those who defraud Medicare and drive up the costs of health care.”

"The two lawsuits were brought under the qui tam, or whistleblower, provisions of the False Claims Act, which permit private citizens with knowledge of fraud against the government to bring an action on behalf of the United States and to share in any recovery. Under the civil settlement announced today, the whistleblowers will receive $1,111,250 of the total recovery."

“This office is determined to protect the integrity of the Medicare system for the citizens of New Jersey and of the United States,” said Paul J. Fishman, U.S. Attorney for the District of New Jersey."

"Assistant Attorney General West noted that today’s settlements was the result of a coordinated effort by the Justice Department’s Civil Division, the U.S. Attorney’s Office for the District of New Jersey, the Department of Health and Human Services Office of Inspector General and Centers for Medicare and Medicaid Services, and the Federal Bureau of Investigation."

"The cases are entitled United States ex rel. Peter Salvatori and Sara C. Iveson v. Robert Wood Johnson University Hospital at Hamilton, Case No.: 08-1265 (JAG) (D.N.J.), and United States ex rel. James Monahan v. Robert Wood Johnson University Hospital at Hamilton, Case No. 02-5702 (JAG) (D.N.J.)."

"This settlement is part of the government’s emphasis on combating health care fraud. One of the most powerful tools in that effort is the False Claims Act, which the Justice Department has used to recover approximately $2.3 billion since January 2009 in cases involving fraud against federal health care programs. The Justice Department’s total recoveries in False Claims Act cases since January 2009 have topped $3 billion. Since 2006, the United States has recovered more than $1.1 billion from hospitals that it alleged engaged in outlier fraud."

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HOSPICE FRAUD NETS MULTIMILLION DOLLAR RECOVERY

"SouthernCare Inc. and its shareholders have agreed to pay the United States a total of $24.7 million to settle allegations that the Birmingham, Ala.-based company submitted false claims to the government for patients treated at its hospice facilities, the Justice Department announced today. SouthernCare operates approximately 99 locations that provide hospice services in 15 states."

“The Medicare hospice benefit is intended to provide compassionate end of life care to terminally ill patients,” said Gregory G. Katsas, Assistant Attorney General of the Civil Division. “This settlement sends a clear message that the Department of Justice will not allow health care providers to take advantage of beneficiaries in their attempts to game the reimbursement system.”

This settlement results from two qui tam suits filed by two former SouthernCare employees on behalf of the United States. The False Claims Act authorizes private parties to file suit against those who defraud the United States and to receive a share of any recovery. The United States will pay $4.9 million to the individuals who filed the actions against SouthernCare.

“Our investigation showed a pattern and practice to falsely admit patients to hospice care who did not qualify and to bill Medicare for that care. This resulted in taxpayers bearing inappropriate costs. This settlement evidences the Department of Justice’s efforts to both protect the public monies and safeguard Medicare beneficiaries,” said Alice H. Martin, U.S. Attorney for the Northern District of Alabama.

http://birmingham.fbi.gov/dojpressrel/pressrel09/bh011509.htm

HEALTH CARE FRAUD CASE NETS RECOVERY OF $1.7 BILLION

HCA Inc. (formerly known as Columbia/HCA and HCA - The Healthcare Company) and HCA subsidiaries agreed to pay the United States over $1.7 Billion including $631 million in 2003 for civil penalties and damages arising from false claims the government alleged it submitted to Medicare and other federal health programs. In 2000, HCA subsidiaries pled guilty to substantial criminal conduct and paid more than $840 million in criminal fines, civil restitution and penalties.  HCA will paid an additional $250 million to resolve overpayment claims arising from certain of its cost reporting practices.  In total, the government will have recovered $1.7 billion from HCA.

This Qui Tam settlement resolved fraud allegations against HCA and HCA hospitals in nine False Claims Act qui tam or whistleblower lawsuits pending in federal court in the District of Columbia. Under the federal False Claims Act, private individuals may file suit on behalf of the United States and, if the case is successful, may recover a share of the proceeds for their efforts. Under the HCA settlement, the whistleblowers will receive a combined share of $151,591,500.00.

http://www.usdoj.gov/opa/pr/2003/June/03_civ_386.htm

Hospital Administrator Whistleblower Qui Tam Lawsuits Under the False Claims Act Can Allow Whistleblowers that Qualify as Realtors of Medicare Fraud a Percentage of the Recovery (Hospital Coding & Billing Administrator, Nursing Home Administrator, Hospice Administrator, and Hospital Administrator Whistleblower Lawyer)

The 1986 Amendment defines a "claim" as:  "...any request or demand which is made to a contractor, grantee, or other recipient if the United States Government provides any portion of the money or property which is requested or demanded, or if the government will reimburse such contractor, grantee, or other recipient for any portion of the money or property which is requested or demanded."

The whistleblower's share of recovery is a maximum of 30 percent. If the government took over the lawsuit, the relator can "continue as a party to the action." The defendant is also required to pay for the relator's attorney fees. The whistleblower is also protected from retaliatory actions by his or her employer. As a result of several  amendments to the False Claims Act and the amount of Medicare fraud that is occuring, qui tam lawsuits increased dramatically.   Though the amendment was first made fore corrupt defense contractors, the amendment has uncovered billions of dollars in health care fraud and the government is recooping billions each years as well is prosecuting those that are committing Medicare fraud.

Anyone who defrauds the government out of revenue can be held accountable under the False Claims Act. Common defendants include defense contractors, health care providers, other government contractors & subcontractors, state and local government agencies,  and private universities. Whistleblowers often include current and former employees of the defrauding company, competitors of government contractors and public interest groups.