Medicare
Compliance Professionals, Medicare Coders, Medicare
Reimbursement Managers, and other health care
professionals are coming forward as the original source of specialized knowledge of
Medicare Billing Fraud and blowing the whistle on
fraudulent Medicare Billing schemes. By coming
forward these Medicare Billing Fraud Whistleblowers are
becoming eligible to receive large economic rewards for
being the first to file on these Medicare billing fraud
scams and are avoiding potential criminal liability for
not reporting Medicare billing fraud.
For more information on a potential
Medicare Billing Fraud, Medicare Coding, and Medicare
Compliance Whistleblower Lawsuit, feel free to
contact
Medicare Billing Fraud and Reimbursement
Whistleblower Lawyer
Jason Coomer via
e-mail message or use our
submission form to discuss a potential pharmaceutical
Medicare Reimbursement Manager Whistleblower lawsuit,
Medicare Code Compliance Whistleblower
Lawsuit,
Medicare Coding Analyst Whistleblower, or other Medicare
Billing Fraud Whistleblower Lawsuit.
Medicare Reimbursement Fraud Whistleblower
Lawsuit Information, Texas Medicare Billing Fraud
Whistleblower Lawsuit Information, Texas Medicare
Reimbursement Manager Whistleblower Lawsuit Information,
Medicare Coding Whistleblower Lawsuit, Medicare
Compliance Whistleblower Lawsuit, and the Call for
Medicare Billing Fraud Whistleblowers
Medicare
and Medicaid billing fraud scams are costing the
United States an estimated one hundred billion
dollars ($100,000,000,000.00) each year and with
approximately 7,000 new people gaining Medicare
benefits each day, the cost of Medicare billing
scams including upcoding, double billing,
unnecessary services, and billing for services not
needed is predicted to continue to increase. To
combat Medicare Billing Fraud Scams and Medicaid
Billing Fraud Scams, the United States government
has amended the Federal False Claims Act to
encourage more Medicare Fraud whistleblowers to step
up and blow the whistle on Medicare Fraud. Medicare
Billing Fraud Whistleblowers and Medicare Payment
Fraud Whistleblowers that are the original source of
specialized knowledge of Medicare Fraud can make
substantial recoveries if they are the first to file
a successful qui tam claim under the Federal False
Claims Act.
Department of Justice Office of Public Affairs
FOR IMMEDIATE RELEASE Tuesday, January 4, 2011 Seven
Hospitals in Six States to Pay U.S. More Than $6.3
Million to Resolve False Claims Act Allegations Related
to Kyphoplasty
WASHINGTON – Seven hospitals located
in Florida, Mississippi, Texas, South Carolina, North
Carolina and Alabama have agreed to pay the United
States a total of more than $6.3 million to settle
allegations that the health care facilities submitted
false claims to Medicare, the Justice Department
announced today.
The settlements resolve allegations
that these hospitals overcharged Medicare between 2000
and 2008 when performing kyphoplasty, a
minimally-invasive procedure used to treat certain
spinal fractures that often are due to osteoporosis. In
many cases, the procedure can be performed safely as a
less costly out-patient procedure, but the government
contends that the hospitals performed the procedure on
an in-patient basis in order to increase their Medicare
billings.
"Hospitals that participate in the
Medicare program must bill for their services accurately
and honestly," said Tony West, Assistant Attorney
General for the Department’s Civil Division. "The
Department of Justice is committed to ensuring that
Medicare funds are expended appropriately."
"These settlements show the
continuing commitment by the U.S. Attorney’s Office to
investigate and recover any improper billings for
kyphoplasty procedures which the hospitals
inappropriately classified as inpatient, rather than
outpatient," said William J. Hochul Jr., U.S. Attorney
for the Western District of New York. "These actions not
only protect taxpayers and the integrity of the Medicare
program in the short term, they will in the long run
help ensure optimal care for Medicare beneficiaries, by
insisting that medicine, and not money, be used to
determine the best course medical decision for a given
case."
The settling facilities include the
following: Lakeland Regional Medical Center, Lakeland,
Fla. ($1,660,134.49); The Health Care Authority of
Morgan County – City of Decatur dba Decatur General
Hospital, Decatur, Ala. ($537,892.88); St.
Dominic-Jackson Memorial Hospital, Jackson, Miss.
($555,949.35); Seton Medical Center, Austin, Texas
($1,232,955.91); Greenville Memorial Hospital,
Greenville, S.C. ($1,026,764.01); Presbyterian
Orthopaedic Hospital, Charlotte, N.C.($637,872.57); and
The Health Care Authority of Lauderdale County and the
City of Florence, Ala., dba the Coffee Health Group, fka
Eliza Coffee Memorial Hospital ($676,038.00).
The settlements with these facilities
follow the settlements that the government reached in
May 2009, September 2009, and May 2010 with 18 other
hospitals for kyphoplasty-related Medicare claims, as
well as the government’s May 2008 settlement with
Medtronic Spine LLC, corporate successor to Kyphon Inc.
Medtronic Spine paid $75 million to resolve allegations
that the company defrauded Medicare by counseling
hospital providers to perform kyphoplasty procedures as
an in-patient procedure, even though the
minimally-invasive procedure should have been done in
many cases as an out-patient procedure.
All of the settling facilities were
named as defendants in a lawsuit filed under the False
Claims Act in 2008 in federal district court in Buffalo,
New York by Craig Patrick and Charles Bates. The qui
tam, or whistleblower, provisions of the Act permit
private citizens, called "relators," to file lawsuits on
behalf of the United States and share in any recovery.
Mr. Patrick of Hudson, Wis., is a former reimbursement
manager for Kyphon, and Mr. Bates was formerly a
regional sales manager for Kyphon in Birmingham, Ala.
The relators will receive a total of approximately $1.1
million as their share of the settlement proceeds.
"Hospitals overcharging Medicare take
critically needed resources necessary to provide quality
care and drive up health care costs," said Daniel R.
Levinson, Inspector General for the U.S. Department of
Health and Human Services. "When Medicare and taxpayers'
dollars are threatened, OIG and its federal partners
will hold perpetrators accountable."
Assistant Attorney General West noted
that the settlements with these hospitals were the
result of a coordinated effort among the Justice
Department’s Civil Division, the U.S. Attorney’s Office
for the Western District of New York, and the Department
of Health and Human Services’ Office of Inspector
General and Office of Counsel to the Inspector General.
This resolution is part of the
government’s emphasis on combating health care fraud and
another step for the Health Care Fraud Prevention and
Enforcement Action Team (HEAT) initiative, which was
announced by Attorney General Eric Holder and Kathleen
Sebelius, Secretary of the Department of Health and
Human Services in May 2009. The partnership between the
two departments has focused efforts to reduce and
prevent Medicare and Medicaid financial fraud through
enhanced cooperation. One of the most powerful tools in
that effort is the False Claims Act, which the Justice
Department has used to recover approximately $4.2
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 $6.8 billion.
More Than $1 Billion Recovered by Justice
Department in Fraud and False Claims in Fiscal Year
2008 More Than $21 Billion Recovered Since 1986
WASHINGTON – The United States
secured $1.34 billion in settlements and judgments
in the fiscal year ending Sept. 30, 2008, pursuing
allegations of fraud against the federal government,
the Justice Department announced today. This brings
total recoveries since 1986, when Congress
substantially strengthened the civil False Claims
Act, to more than $21 billion.
"Now, more than ever, it is
crucial that taxpayer dollars aren't lost to fraud,"
said Gregory G. Katsas, Assistant Attorney General
for the Department’s Civil Division. "The billion
dollars collected this year is only part of the
story. By rooting out fraud and vigorously pursuing
it, the Department, with the help of concerned
citizens who report fraud in hotline calls and in
qui tam complaints, undoubtedly saves the country
many times that amount in aborted schemes and
misconduct."
Assistant Attorney General Katsas
also paid tribute to Senator Charles Grassley of
Iowa and Representative Howard L. Berman of
California who sponsored the 1986 amendments to the
False Claims Act, the government's primary weapon to
fight government fraud. "Without this important
legislation strengthening the Act and, in
particular, the qui tam provisions which encourage
private citizens to uncover government fraud, such
recoveries would not have been possible."
Almost 78 percent of this year’s
recoveries are associated with suits initiated by
private citizens (known as "relators") under the
False Claims Act's qui tam provisions. These
provisions authorize relators to file suit on behalf
of the United States against those who have falsely
or fraudulently claimed federal funds. Such cases
run the gamut of federally funded programs from
Medicare and Medicaid to defense procurement
contracts, disaster assistance loans and
agricultural subsidies. Persons who knowingly make
false claims for federal funds are liable for three
times the government’s loss plus a civil penalty of
$5,500 to $11,000 for each claim.
Relators recover 15 to 25 percent
of the proceeds of a successful suit if the United
States intervenes in the qui tam action, and up to
30 percent if the government declines and the
relator pursues the action alone. In fiscal year
2008, relators were awarded $198 million. (This
figure does not include relator shares awarded after
Sept. 30, 2008.)
As in the last several years,
health care accounted for the lion's share of fraud
settlements and judgments–$1.12 billion. This number
includes both qui tam claims and those initiated by
the United States. The Department of Health and
Human Services reaped the biggest recoveries,
largely attributable to its Medicare program and the
federal/state Medicaid program which funds health
care for the needy. Recoveries were also made by the
Office of Personnel Management which administers the
Federal Employees Health Benefits Program, the
Department of Defense for its TRICARE insurance
program, the Department of Veterans Affairs and
others.
The largest health care
recoveries came from pharmaceutical companies and
related entities. Settlements with Cephalon Inc.,
Merck & Co. and CVS Caremark Corp. accounted for
more than $640 million. In addition to federal
recoveries, these pharmaceutical fraud cases
returned $430 million to state Medicaid programs.
The Civil Division’s
investigation of the pharmaceutical industry is part
of a Department-wide effort. Typical allegations
include "off-label" marketing, which is the illegal
promotion of drugs or devices that are billed to
Medicare and other federal health care programs, for
uses that were neither found safe and effective by
the Food and Drug Administration nor supported by
the medical literature; paying kickbacks to
physicians, wholesalers and pharmacies to induce
drug or device purchases; establishing inflated drug
prices knowing that federal health care programs use
these prices to reimburse providers, then marketing
the "spread" between the federal reimbursement and
the provider’s lower cost to induce drug purchases;
and knowingly failing to report the company’s true
"best price" for a drug to reduce rebates owed to
the Medicaid program.
The Department also collected
$133 million in defense procurement fraud. Defense
contract recoveries included a $53 million
settlement with Pratt & Whitney, a division of
United Technologies Corporation, and PCC Airfoils
LLC, a subsidiary of Precision Castparts
Corporation. The settlement resolved allegations
that Pratt & Whitney and PCC Airfoils knowingly
submitted false claims to the Air Force for
defective turbine blades sold to the government to
retrofit the F100-PW-220 engines in F-16 and F-15
aircraft. This case was pursued as part of a
National Procurement Fraud initiative, launched in
October 2006, to promote the early detection,
identification, prevention and prosecution of
procurement fraud.
FACT SHEET: SIGNIFICANT
RECOVERIES IN FISCAL YEAR 2008
Among the Department’s most
significant settlements and judgments in fiscal year
2008 were:
* $361.5 million from Merck &
Company to resolve allegations that the
pharmaceutical manufacturer knowingly failed to pay
proper rebates to Medicaid and other government
health care programs, and paid kickbacks to health
care providers to induce them to prescribe the
company’s products. The settlement resulted from two
lawsuits brought under the qui tam provisions of the
False Claims Act.
In the first, which accounted for
$221.9 million of the $361.5 settlement, a former
Merck employee alleged that the company violated the
Medicaid Rebate Statute by providing deep discounts
to hospitals that used its drugs Zocor and Vioxx in
place of competitors’ brands, without reporting
those discounts and other cost information to
reflect its "best price," as required by the statute
to ensure that Medicaid obtains the benefit of the
same price concessions other purchasers enjoy. This
suit also alleged that Merck paid kickbacks to
physicians, disguised as fees for training,
consultation, and market research, to induce them to
prescribe its drugs, also contrary to law. The
United States paid the relator $46.6 million as his
share of the settlement under the False Claims Act’s
qui tam provisions. In addition to the federal
recovery, Merck paid $162 million to state Medicaid
programs.
In the second lawsuit, which
accounted for the remaining $139.6 million of the
settlement, a physician alleged that Merck provided
deep discounts to hospitals to induce them to
administer its antacid, Pepcid, as a means to boost
sales through continued use after the patient’s
discharge. The suit went on to allege, similar to
the first suit, that Merck knowingly failed to
report these discounts as required by the Medicaid
Rebate Statute, which resulted in illegal and
inflated claims to federal and state Medicaid
programs. In addition to paying the United States
$139.5 million in federal claims, Merck paid $114
million to settle state Medicaid claims. The relator
received $24 million as his federal share of the
settlement and an additional sum for the state
recoveries. Merck also entered into a Corporate
Integrity Agreement with the Inspector General of
the Department of Health and Human Services (HHS) to
ensure compliance with federal health insurance
programs in the future.
For the original press release,
see:
http://www.usdoj.gov/opa/pr/2008/February/08_civ_094.html
http://www.usdoj.gov/usao/pae/News/Pr/2008/feb/steinkrelease.pdf
* $258 million from Cephalon Inc.
to resolve claims that the company marketed three
drugs for uses not approved by the Food and Drug
Administration (FDA). By promoting the drugs for
so-called "off label" uses, Cephalon caused
providers to charge federal health insurance
programs such as Medicare, Medicaid, TRICARE and the
Federal Employees Health Benefits Program for
unapproved uses of the drugs not covered by the
programs. The settlement resolved four lawsuits,
three of which were brought by former Cephalon sales
representatives under the qui tam provisions of the
False Claims Act. Consistent with those provisions,
the relators who filed the suits will share $46.7
million as their part of the settlement. In addition
to the $258 million recovered for federal programs,
the United States recovered $116 million for the
Medicaid programs in 14 states and the District of
Columbia. Cephalon also pleaded guilty to related
criminal charges, paid $50 million in fines and
forfeitures and entered into a five-year Corporate
Integrity Agreement with the Inspector General of
HHS to ensure strict compliance in the future.
For the original press release,
see:
http://www.usdoj.gov/opa/pr/2008/September/08-civ-860.html
* $225 million from Amerigroup
Corporation to settle both federal and state
allegations that Amerigroup, together with its
Illinois subsidiary, systematically avoided
enrolling pregnant women and other high-cost
patients in the company’s managed care program in
Illinois. The program was funded by Medicaid, which
required open enrollment to all eligible
beneficiaries. By excluding pregnant women and other
high-cost patients, Amerigroup increased its profits
in conflict with the law. The United States and
Illinois jointly brought suit under the federal
False Claims Act and the Illinois Whistleblower
Reward and Protection Act. In October 2006,
following a lengthy trial, the court entered
judgment for $334 million. Amerigroup appealed and
the parties entered negotiations leading to
settlement. The relator received $56.25 million as
his share of the federal and state recoveries. In
conjunction with the settlement, Amerigroup entered
into a Corporate Integrity Agreement with the
Inspector General of HHS to ensure future
compliance.
For the original press release,
see:
http://www.usdoj.gov/opa/pr/2008/August/08-civ-723.html
* $75 million to settle claims
that Kyphon Inc., now Medtronic Spine LLC, violated
the False Claims Act by knowingly causing the
submission of false claims to Medicare for its
kyphoplasty procedure–a minimally-invasive surgery
used to treat compression fractures of the spine.
The settlement resolved a lawsuit filed by two
former Kyphon employees under the qui tam provisions
of the False Claims Act. The suit alleged that
Kyphon engaged in a seven-year marketing scheme that
resulted in certain hospitals billing Medicare for
kyphoplasties performed on an inpatient basis rather
than for less costly and clinically appropriate
outpatient kyphoplasty treatment. This conduct
resulted in the Medicare program paying more for
inpatient kyphoplasty procedures. The relators
received a total of $14.9 million as their share of
the settlement. In conjunction with the settlement,
Kypon entered into a Corporate Integrity Agreement
with the Inspector General of HHS to ensure future
compliance.
For the original press release,
see:
http://www.usdoj.gov/opa/pr/2008/May/08-civ-455.html
* $74 million from Staten Island
University Hospital (SIUH) to resolve two False
Claims Act qui tam suits and two other matters. In
the first action, a physician and former SIUH
Director of Chemical Dependency Services, filed suit
alleging that SIUH fraudulently billed Medicare and
Medicaid for substance abuse and alcohol
detoxification services provided to inpatients in
unlicensed beds, in violation of state law, between
1994 and 2000. SIUH paid the United States $11.8
million in settlement of this qui tam action, with
the relator receiving $2.3 million as his share of
the government’s recovery. In related allegations of
inflated Medicaid billings asserted under New York
State’s false claims statute, SIUH paid New York
$14.88 million, with the relator receiving $2.97
million as his share of the state’s recovery.
In the second action, the widow
of an SIUH cancer patient filed suit alleging that
between 1996 and 2004, SIUH submitted false claims
to Medicare and TRICARE using incorrect codes for
cancer treatments not covered by the programs. SIUH
paid the United States $25 million, including a
relator share award of $3.75 million. In the third
matter, the United States alleged that SIUH
deliberately inflated the number of residents it
employed to fraudulently increase Medicare
reimbursement between 1996 and 2003. SIUH paid the
United States $35.7 million in settlement of this
matter. Lastly, SIUH paid the United States $1.47
million to settle allegations that it billed
Medicare and Medicaid for treating psychiatric
patients in unlicensed beds from 2003-2005. In
conjunction with the settlement, SIUH also entered
into a Corporate Integrity Agreement with the
Inspector General of HHS to ensure future
compliance.
For the original press release,
see:
http://www.usdoj.gov/usao/nye/pr/2008/2008sep15.html
* $60 million from Lester E. Cox
Medical Centers, a health care system headquartered
in Springfield, Mo., to settle claims that it
violated the False Claims Act, the Anti-Kickback
Statute and the Stark Statute between 1996 and 2005.
The United States alleged that Cox entered into
illegal financial relationships with referring
physicians at a local physician group and engaged in
improper billing practices with respect to Medicare.
Under the Stark Statute, providers such as Cox are
prohibited from billing Medicare for referrals from
doctors with whom the providers have a financial
relationship, unless that relationship falls within
certain exceptions. The United States contended that
Cox and the referring physicians ran afoul of the
Stark Statute, as well as the Anti-Kickback Statute,
which prohibits offering inducements to providers in
return for patient referrals. The settlement also
resolves claims that Cox included non-reimbursable
costs on its Medicare cost reports and improperly
billed for dialysis services. In conjunction with
the settlement, Cox entered into a Corporate
Integrity Agreement with the Inspector General of
HHS to ensure future compliance.
For the original press release,
see:
http://www.usdoj.gov/opa/pr/2008/July/08-civ-638.html
http://www.usdoj.gov/usao/mow/news2008/cox.settlement.htm
* $53 million from Pratt &
Whitney, a division of United Technologies
Corporation, and PCC Airfoils LLC, a subsidiary of
Precision Castparts Corporation, to resolve
allegations that the companies knowingly submitted
false claims for defective turbine blades purchased
by the Air Force to retrofit the F100-PW-220 engines
found in F-16 and F-15 aircraft. The settlement
includes corrective action to replace defective
blades and inspection of potentially serviceable
blades to ensure their integrity. The case was
pursued as part of a National Procurement Fraud
Initiative launched in October 2006, to promote the
early detection, identification, prevention and
prosecution of procurement fraud.
For the original press release,
see:
http://www.usdoj.gov/opa/pr/2008/August/08-civ-675.html
* $26 million from St. Joseph’s
Hospital of Atlanta to resolve allegations that the
hospital falsely claimed Medicare reimbursement for
inpatient admissions that were, in fact, less costly
outpatient visits. A registered nurse, formerly
employed by the hospital, initiated suit under the
False Claims Act’s qui tam provisions. The complaint
alleged that the hospital improperly billed for
short inpatient admissions, usually of one day or
less, when the service should have been billed as an
outpatient "observation" or emergency room visit.
Medicare reimburses hospitals a higher rate for
inpatient admissions than it does for observation
care or emergency room visits. The nurse who
triggered the investigation received $4.94 million
as her share of the recovery. St. Joseph’s entered
into a Corporate Integrity Agreement with the
Inspector General of HHS in conjunction with the
settlement, to ensure future compliance.
For the original press release,
see:
http://www.usdoj.gov/usao/gan/press/2007/12-21-07.pdf
* $23.2 million from Bechtel
Infrastructure Corp. and PB Americas Inc. to settle
allegations of false claims for federal highway
funds in connection with the firms’ failure to
provide adequate management and quality assurance
services during the construction of the Central
Artery Tunnel, known as the Big Dig, in Boston. The
recovery, part of a $458 million settlement of state
and federal claims, resolved parts of a qui tam
lawsuit, a related federal investigation and
additional claims that Bechtel and PB Americas
violated federal and state criminal and civil laws
in connection with their services on the Big Dig. In
addition to the federal recovery, the companies paid
$40 million in state claims and $335 million into a
state warranty fund for future repairs to the Big
Dig. The private citizen who filed the suit received
$54,000 and $96,000 as his share of the federal and
state recoveries, respectively.
For the original press release,
see:
http://www.usdoj.gov/opa/pr/2008/January/08_crt_048.html
http://boston.fbi.gov/dojpressrel/pressrel08/govtclaimsettlement012308.htm
* $21.1 million from CVS Caremark
Corp. to settle claims that from 2000-2006, the
company illegally switched patients from the tablet
version of the drug Ranitidine (generic Zantac) to a
more expensive capsule version for the sole purpose
of increasing Medicaid reimbursement. For example,
CVS pharmacies in Illinois would charge Medicaid
$79.80 for 60 Ranitidine capsules, rather than
$17.10 for the tablets prescribed, increasing
reimbursement by $62.70 on a single prescription.
CVS Caremark is headquartered in Rhode Island and
operates more than 6,000 pharmacies nationwide. The
settlement resolves qui tam claims under federal and
state false claims statutes. In addition to the
federal recovery, CVS Caremark paid $15.6 million to
23 states and the District of Columbia. The qui tam
plaintiff received $4.3 million as his share of the
federal and state settlements. CVS Caremark also
entered into a Corporate Integrity Agreement with
the Inspector General of HHS to ensure future
compliance.
For the original press release,
see:
http://www.usdoj.gov/opa/pr/2008/March/08_crt_214.html
Department of Justice Office of Public Affairs
FOR IMMEDIATE RELEASE Thursday, September 24, 2009
Detroit Clinic Owner and Manager Plead Guilty to
Medicare Fraud Charges
WASHINGTON – Clinic owners and
operators Jose Martinez and Denisse Martinez pleaded
guilty today in U.S. District Court in Detroit to
participating in a conspiracy to defraud the Medicare
program, Assistant Attorney General Lanny A. Breuer of
the Criminal Division, U.S. Attorney Terrence Berg of
the Eastern District of Michigan and Daniel R. Levinson,
Inspector General of the Department of Health & Human
Services (HHS) announced.
Jose Martinez, 33, and Denisse
Martinez, 27, each pleaded guilty to one count of
conspiracy to commit health care fraud before U.S.
District Judge Victoria Roberts. At sentencing, which is
scheduled for Feb. 18, 2010, both defendants face a
statutory maximum of 10 years in prison and a $250,000
fine.
According to court documents, Jose
Martinez, in September 2006, opened RDM Center Inc., a
Canton, Mich., medical clinic purporting to specialize
in providing injection and infusion services to Medicare
beneficiaries. Jose Martinez’s then-wife, Denisse
Martinez, managed and operated the clinic.
In their pleas, both defendants
acknowledged that they hired a physician and other
employees to work at RDM Center in order to create the
appearance that the clinic was a legitimate health care
facility providing necessary services to patients, when
in fact, everyone working at the clinic knew that it was
operated for the sole purpose of defrauding Medicare.
In their pleas, both Jose and Denisse
Martinez admitted that d uring the time that the RDM
Center was open, the clinic routinely billed the
Medicare program for services that were medically
unnecessary or never provided. Both defendants admitted
that they purchased only a small fraction of the
medications for which the clinic billed the Medicare
program. Both defendants also admitted that patients
were prescribed medications at the clinic based not on
medical need, but on which medications were likely to
generate Medicare reimbursements.
Denisse Martinez admitted in her plea
that, despite having no medical training, she completed
the clinic’s patient records by filling in, among other
things, the "diagnosis" and "treatment" sections of the
patient charts, which were then provided to the
physician for his signature.
According to information contained in
the plea documents, Medicare beneficiaries were not
referred to RDM Center by their primary care physicians,
or for any other legitimate medical purpose, but rather
were recruited to come to the clinic through the payment
of kickbacks. In exchange for their kickbacks, the
Medicare beneficiaries would visit the clinic and sign
false documents indicating that they had received the
services billed to Medicare. Kickbacks came in the form
of cash and prescriptions for controlled substances.
Jose Martinez stated in his plea that
he provided cash to a patient recruiter for the purpose
of paying Medicare beneficiaries to sign paperwork
indicating that they had received infusion and injection
therapy services which they did not in fact receive.
Denisse Martinez stated in her plea that she understood
the patients at the clinic were induced to visit RDM
Center through the payment of kickbacks. Both defendants
further admitted to being aware that certain Medicare
beneficiaries demanded that they be provided
prescription drugs, including Vicodin, in exchange for
their participation in the fraudulent scheme and that
such drugs were in fact provided.
Both defendants admitted in their
pleas that between approximately November 2006 and March
2007, they and their co-conspirators filed $970,631 in
false and fraudulent claims with the Medicare program.
According to court documents, Medicare actually paid
more than $649,000 of those false claims.
The case is being prosecuted by Trial
Attorneys John K. Neal and Benjamin D. Singer of the
Criminal Division’s Fraud Section and by Special
Assistant U.S. Attorney Thomas W. Beimers of the Eastern
District of Michigan. The FBI and the HHS Office of
Inspector General (HHS-OIG) conducted the investigation.
The case was brought as part of the Medicare Fraud
Strike Force, supervised by the Criminal Division’s
Fraud Section and the U.S. Attorney’s Office for the
Eastern District of Michigan.
Since the inception of Strike Force
operations in March 2007 – Miami (Phase One), Los
Angeles (Phase Two), Detroit (Phase Three) and Houston
(Phase Four) – the Strike Force has obtained indictments
of 300 individuals and organizations that collectively
have billed the Medicare program for more than $680
million. In addition, HHS’s Centers for Medicare and
Medicaid Services, working in conjunction with the
HHS-OIG, are taking steps to increase accountability and
decrease the presence of fraudulent providers.
Each of the Medicare Fraud Strike
Force teams are led by a federal prosecutor from the
Criminal Division’s Fraud Section or the U.S. Attorney’s
Office. Each team has an agent from the FBI and HHS-OIG.
To learn more about the Health Care
Fraud Prevention and Enforcement Action Team, or "HEAT,"
go to: www.stopmedicarefraud.gov
LARGEST HEALTH CARE FRAUD CASE IN U.S. HISTORY
SETTLED HCA INVESTIGATION NETS RECORD TOTAL OF $1.7
BILLION
WASHINGTON, D.C. - HCA Inc. (formerly
known as Columbia/HCA and HCA - The Healthcare Company)
has agreed to pay the United States $631 million in
civil penalties and damages arising from false claims
the government alleged it submitted to Medicare and
other federal health programs, the Justice Department
announced today.
This settlement marks the conclusion
of the most comprehensive health care fraud
investigation ever undertaken by the Justice Department,
working with the Departments of Health and Human
Services and Defense, the Office of Personnel Management
and the states. The settlement announced today resolves
HCA's civil liability for false claims resulting from a
variety of allegedly unlawful practices, including cost
report fraud and the payment of kickbacks to physicians.
Previously, on December 14, 2000, HCA
subsidiaries pled guilty to substantial criminal conduct
and paid more than $840 million in criminal fines, civil
restitution and penalties. Combined with today's
separate administrative settlement with the Centers for
Medicare & Medicaid Services (CMS), under which HCA will
pay an additional $250 million to resolve overpayment
claims arising from certain of its cost reporting
practices, the government will have recovered $1.7
billion from HCA, by far the largest recovery ever
reached by the government in a health care fraud
investigation.
"Health care providers and
professionals hold a public trust, and when that trust
is violated by fraud and abuse of program funds, and by
the payment of kickbacks to the physicians on whom
patients and the programs rely for uncompromised medical
judgment, health care for all Americans suffers," Robert
D. McCallum, Jr., Assistant Attorney General for the
Civil Division said. "This settlement brings to a close
the largest multi-agency investigation of a health care
provider that the United States government has ever
undertaken and demonstrates the Department of Justice's
ongoing resolve and commitment to pursue all types of
fraud on American taxpayers, and health care program
beneficiaries."
"Let this case be a continuing
reminder to all that in the fight against health care
fraud this office will not be deterred," said Acting
Principal Deputy Inspector General Dara Corrigan.
“Medicare dollars paid to provide ever more expensive
health care services to the country's taxpayers should
never be fraudulently diverted. This is our job and our
trust and we take these duties very seriously," Corrigan
concluded.
This latest settlement resolves 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 settlement, the whistleblowers
will receive a combined share of $151,591,500, the
highest combined qui tam award ever paid out by the
government.
"We are grateful for the assistance
given by the whistleblowers over the course of the past
nine years of investigation and litigation,” McCallum
said. “And we are proud of the work of government
personnel as well as counsel for the whistleblowers, who
together pursued these matters through investigation and
strenuous litigation. This result demonstrates the
commitment of the Department to the qui tam statute and
that the statute works as Congress intended."
Under the first of three agreements
announced today, which becomes effective upon the
court's dismissal of the lawsuits, HCA will pay nearly
$620 million to resolve eight whistleblower lawsuits in
which the government had intervened alleging that HCA
systematically defrauded Medicare, Medicaid and other
federally funded health care programs through schemes
dating back to the late 1980s. HCA will pay an
additional $11 million to resolve separate allegations
of improper HCA billing practices.
The settlement requires HCA to pay:
* $356 million to resolve
whistleblower lawsuits alleging that HCA engaged in a
series of schemes to defraud Medicare, Medicaid and
TRICARE, the military’s health care program, through
hospital cost reports, the year end claims submitted by
hospitals to the government to reconcile payments
received throughout the year with amounts they claim are
actually owed. In 2001, a subsidiary of Nashville-based
HCA, Columbia Management Companies, Inc., pled guilty in
the Middle District of Florida to related charges on
eight counts of making false statements to the United
States and paid $22.6 million in criminal fines. An
additional amount of $20 million of the settlement is
being paid toward a resolution of cost reporting fraud
allegations pursued separately by James Alderson and
John Schilling, the relators who filed the lawsuits. In
total, the two relators are to receive a total of $100
million as their statutory share of the settlement. *
$225.5 million to resolve lawsuits alleging that HCA
hospitals and home health agencies unlawfully billed
Medicare, Medicaid and TRICARE for claims generated by
the payment of kickbacks and other illegal remuneration
to physicians in exchange for referral of patients. In
2001, Columbia Management Companies, Inc., pled guilty
to one count of conspiracy to pay kickbacks and other
monetary benefits to doctors in violation of the
Medicare Antikickback Statute and paid a $30 million
criminal fine. Dr. James Thompson, a doctor who filed
suit against the company in 1995, will receive $41.5
million as his statutory share of the settlement. Gary
King, a former HCA employee, will receive $5 million and
Ann Mroz, a former HCA nurse, will receive a share of
$837,500. * $17 million to resolve allegations that
certain company-owned hospitals billed Medicare for
unallowable costs incurred by a contractor that operated
HCA wound care centers, and for a non-covered drug that
the contractor manufactured and sold to hospital
patients. The 2001 Columbia Management Companies' guilty
plea concerning cost report fraud included a charge
related to wound care center costs. HCA's wound care
center management contractor, Curative Healthcare
Services, Inc., previously paid $16.5 million to resolve
related allegations pending at one time in these same
lawsuits. Joseph "Mickey" Parslow, a former HCA
financial officer, will receive $2,990,000 and Francesco
Lanni, a former Reimbursement Manager at the Wound Care
Center at New York Methodist Hospital in Brooklyn, New
York, will receive a share of $680,000. * $5 million to
resolve allegations concerning the transfer of patients
from HCA facilities to other facilities and the claiming
of excessive costs for those transfers. * $5 million to
resolve allegations that HCA's Lawnwood Regional Medical
Center in Fort Pierce, Florida submitted false claims in
Medicare cost reports by inflating its entitlement to
funds to treat indigent patients and by shifting
employee salary costs in order to increase its
reimbursement from the federal health care program. *
$950,000 to settle allegations made by Michael Marine
that HCA improperly shifted its home office costs to
hospitals. Marine will receive a share of $116,500.
Today's settlement agreement
incorporates the terms of a Corporate Integrity
Agreement executed by HCA and the Office of the
Inspector General, Department of Health and Human
Services in December 2000 that obligated the company to
engage in significant and comprehensive compliance
efforts into 2009.
In a separate agreement, HCA agreed
to pay $1.5 million to resolve allegations that an
Atlanta, Georgia hospital, West Paces Medical Center,
paid kickbacks for the referral of diabetes patients.
Those allegations had been pursued since 1996 by a
whistleblower in a case in which the United States had
declined to intervene, captioned U.S. ex rel. Pogue v.
American Healthcorp, Inc. et al.. Pogue, a former
employee of a co-defendant in the case, Diabetes
Treatment Centers of America, will receive a share of
$405,000 from the HCA settlement. Pogue continues to
litigate claims against his former employer and a group
of Atlanta physicians.
Additionally, a state negotiating
team appointed by the National Association of Medicaid
Fraud Control Units has reached agreement with HCA to
resolve related issues with affected state Medicaid
plans for $17.5 million, representing direct state
losses. The terms of that agreement are being finalized
by the parties and are not part of today's settlement.
Today's administrative agreement
between HCA and CMS will require HCA to pay CMS $250
million in order to resolve claims they maintained
against each other arising from HCA's hospital cost
reports and home office cost statements for cost
reporting periods ending July 31, 2001. These claims
resulted from HCA cost reports that were not processed
since 1997 as a result of the government's
investigation.
FOR IMMEDIATE RELEASE CIV FRIDAY, AUGUST 29,
1997 (202) 616-2765 TDD (202) 514-1888
U.S. SUES TWO TENNESSEE MEN AND RELATED HEALTH
CARE COMPANIES
WASHINGTON, D.C. -- The Department of
Justice today sued a health care management company and
the former executive director of a home health agency,
both of Chattanooga, Tennessee, for fraudulently using
the home health agency and others to overcharge Medicare
at least $30 million for inflated management expenses
related to the operation of several home health care
agencies.
The companies and the wife of the
owner of the management company also were named as
defendants.
Assistant Attorney General Frank W.
Hunger, in charge of the Civil Division, said the
complaint was filed in U.S. District Court for the
Eastern District of Tennessee at Chattanooga against
William T. Rogers; James C. Callaway Jr.; Alpha Medical
Inc., formerly Alpha Medical Management Inc. (Alpha);
and the not-for-profit Superior Home Health Care of
Chattanooga Inc. (SHHC-C), also known as The Charitable
Healthcare Foundation Inc. Rogers, Callaway, Alpha and
SHHC-C were charged with violations of the civil False
Claims Act and common law. Rogers' spouse, Gayle M.
Rogers, was sued solely under common law.
"The Department will not tolerate any
fraud or cheating of the Medicare program," said Hunger.
"Those who engage in deceptive practices or otherwise
abuse the program will be held accountable for their
actions. We want each and every health care provider
participating in the Medicare program to understand that
clearly."
William Rogers is the sole
shareholder of Alpha, the suit said. SHHC-C was a home
health agency that Alpha managed. Alpha also managed
other home health agencies that operated under the name
of Superior Home Health Care, some of which initially
were owned by Callaway then later sold to other SHHC-C
directors, and other agencies that were owned by
relatives of William and Gayle Rogers.
The complaint alleges that William T.
Rogers, Callaway, Alpha and SHHC-C conspired with each
other and others to obtain Medicare reimbursement for
the management fees the various home health agencies
paid Alpha. The suit says the fees were not reimbursable
because Alpha and the home health agencies were related
organizations within the meaning of Medicare rules. The
agencies, therefore, were entitled only to reimbursement
up to the amount of Alpha's reasonable and related costs
for patient care in managing the home health agencies,
excluding any profit.
According to the complaint, the
reimbursement claims exceeded Alpha's reasonable costs
by more than $30 million, which were salaries Alpha paid
William T. and Gayle Rogers in 1990 through 1993.
The complaint maintains that the
parties were related because William T. Rogers was the
president of SHHC-C's board and was SHHC-C's executive
director, administrator, treasurer and bank note
guarantor, when Alpha initially contracted with SHHC-C
to manage SHHC-C in 1986. Gayle Rogers also was on the
SHHC-C board at that time.
Moreover, at that time, Callaway, a
long-time personal and business associate of William T.
Rogers, was a director of SHHC-C, according to the
complaint. The other members of the SHHC-C board at the
time were Todd Gardenhire, Rogers' stockbroker; Charles
Levine, Rogers' certified public accountant; and Charles
Johnson, Callaway's brother-in-law.
The complaint further alleges that
Callaway, while a director of SHHC-C, contracted with
Alpha to manage three home health agencies he owned. Two
other home health agencies that contracted for Alpha's
management were owned by two of Gayle Rogers' sisters'
husbands. Gardenhire, Levine, Johnson and Gayle Rogers'
sisters' husbands were not named as defendants in the
suit.
According to the complaint, William
T. Rogers, Callaway, SHHC-C, and Alpha also conspired to
submit false bid letters to the Medicare fiscal
intermediary in 1988 and 1990 to prevent a finding that
the organizations were related. The falsified documents
allegedly were intended to establish the existence of
competitive bids or a market search for other management
companies that, in fact, never occurred.
Under the False Claims Act, the
United States may be awarded three time its damages plus
a $5,000 to $10,000 civil penalty for each false claim
or statement.
Department of Justice Office of Public Affairs
FOR IMMEDIATE RELEASE Friday, January 15, 2010 General
Manager of Houston Medical Supply Company Pleads Guilty
to Conspiracy to Commit Health Care Fraud
Manual Deluna has pleaded guilty to
one count of conspiracy to commit health care fraud.
Deluna, 48, pleaded guilty on Jan.
14, 2010, before U.S. District Court Judge Ewing Werlein
Jr., in connection with Deluna’s role in Memorial
Medical Supply, a Houston durable medical equipment
company. Deluna was the general manager of Memorial
Medical Supply, and began his association with the
company in approximately October 2007. Deluna, along
with co-defendants Sunny Robinson, Lisa Jones and
Shirley A. Chavis, was originally indicted on July 22,
2009.
In connection with his plea, Deluna
admitted that he and others illegally obtained protected
Medicare beneficiary health information including names,
dates of birth, medical histories, and Medicare and
Social Security numbers from individuals and home health
agencies. Deluna admitted that this health information
was used to submit false and fraudulent claims to
Medicare for reimbursement for equipment such as
"Arthritis Kits," power wheelchairs, and diabetic and
incontinence supplies. Deluna admitted that the Medicare
beneficiaries in many instances did not order or even
need the medical equipment, nor did a physician actually
prescribe these items. Deluna admitted that in several
instances, Memorial Medical Supply also submitted false
claims to Medicare in the names of Medicare
beneficiaries who were deceased. Deluna admitted that
from May 2006 through January 2009, Memorial Medical
Supply submitted claims to Medicare in excess of $4.3
million.
Deluna remains on bond pending
sentence, which is currently scheduled for April 9,
2010. Robinson, Jones and Chavis remain on bond pending
trial.
This case is being prosecuted by
Special Assistant U.S. Attorney Justin Blan, and was
investigated by agents of the HHS-OIG, the Office of
Personnel Management, the FBI and the Texas Attorney
General’s Office - Medicaid Fraud Control Unit. This
prosecution is the latest in the Medicare Fraud Strike
Force’s efforts in the Houston area. The Strike Force is
supervised by the U.S. Attorney’s Office for the
Southern District of Texas and the Criminal Division’s
Fraud Section.
Since the inception of Strike Force
operations in March 2007 - Miami (Phase One), Los
Angeles (Phase Two), Detroit (Phase Three), Houston
(Phase Four), Brooklyn (Phase Five), Tampa (Phase Six)
and Baton Rouge (Phase Seven) - the Strike Force has
obtained indictments of more than 475 individuals and
organizations that collectively have billed the Medicare
program for more than $1 billion. In addition, HHS’s
Centers for Medicare and Medicaid Services, working in
conjunction with the HHS-OIG, are taking steps to
increase accountability and decrease the presence of
fraudulent providers.
Medicare Coding Whistleblower
Lawsuit Information,
Medicare Reimbursement Whistleblower Lawsuit Information,
Medicare Compliance Whistleblower Lawsuit Information, and Medicare
Marketing Fraud and Kickback Lawsuit Information
Pharmaceutical representative
whistleblowers,
medical device sales representative whistleblowers, and
drug marketing executive whistleblowers are stepping up
and exposing Medicare marketing
fraud that is costing taxpayers billions. The
economic incentive for these pharmaceutical representative
whistleblowers,
medical device sale representative whistleblowers, and
drug marketing executive whistleblowers is that if they
are an original source with special knowledge of fraud
and are the first to file, they receive a portion of the
money that the government recovers. Depending on
the extent of the fraud, qui tam recoveries for the
government can be in the billions of dollars and
whistleblower recoveries can be in the hundreds of
millions of dollars.
There are several keys to a
successful False Claims Act Qui Tam Whistleblower action
including 1) obtaining original and specialized
information of the fraud, 2) being the first to file
regarding the specific fraud, and 3) protecting the
whistleblower for retaliation.
Original and Specialized Information of Fraud
is Essential for Medicare Coding Whistleblower
Lawsuits,
Medicare Reimbursement Whistleblower Lawsuits,
Medicare Compliance Whistleblower Lawsuits, and Medicare
Marketing Fraud and Kickback Lawsuits
As insiders it is common for pharmaceutical representative
whistleblowers,
medical device sales representative whistleblowers, drug marketing representative
whistleblowers, and other marketing executives to
specialized knowledge of marketing fraud and fraudulent
marketing schemes. As such, it is important for
the pharmaceutical representative whistleblower,
medical device sales representative whistleblower, drug marketing representative
whistleblower, or other marketing executive
whistleblower to obtain and preserve evidence of the
marketing fraud. Whether this evidence is in
e-mail messages, memos, marketing plans, marketing
materials, recordings, or other documents, it is
important for the whistleblower to have evidence of the
marketing fraud. It is also often helpful to have
fellow whistleblowers that can help build the Medicare
Fraud or Off-Label Marketing Fraud case.
Being the First to File on the Fraud is
Essential for Recovery Under the False Claims Act and
can Prevent Potential Criminal Liability in Medicare Coding
Fraud Scams,
Medicare Reimbursement Fraud Scams,
Medicare Compliance Fraud Scams, and Medicare
Marketing Fraud and Kickback Scams
It is also essential to not delay in
coming forward with a False Claim Act Qui Tam Action as
the first whistleblower to file is eligible to be a
relator and make a large recovery for exposing the
fraud. Additionally, when the fraudulent scheme is
exposed, the people that kept the fraud secret can
sometimes be found liable for criminal activity for not
exposing the fraud that was being committed and further
be held liable for continuing criminal activity.
Medicare Coding Whistleblower
Protection,
Medicare Reimbursement Whistleblower Protection,
Medicare Compliance Whistleblower Protection, and Medicare
Hospital Executive Whistleblower Protection under the
Federal False Claims Act
It is also important to understand
potential whistleblower protections under the False
Claims Act and to discuss with an attorney how to
prepare for potential retaliation or aggressive attacks
by the employer or contractor. For more
information on this topic please go to the following web
page on
False Claims Act Lawsuit Whistleblower Protections.
Medicare Compliance Whistleblower Lawsuit
Information, Medicare Billing Fraud Whistleblower Lawsuit
Information, Medicare Reimbursement Manager Whistleblower
Lawsuit Information, and
Medicare Reimbursement Manager, Coder, & Compliance Whistleblower Protections (Texas
Medicare Reimbursement and Compliance Whistleblower Lawyer)
Health care companies that are
committing Medicare billing fraud scams are being
brought to justice by whistleblowers and law
enforcement.
Medicare Fraud
Whistleblower Lawyer Jason Coomer is working
with other powerful Medicare whistleblower lawyers to
help Medicare fraud whistleblowers blow the whistle on
Medicare fraud.
He works with San Antonio Medicare Billing Fraud Lawyers, Dallas
Medicare Billing Fraud
Lawyers, Houston Medicare Billing Fraud Lawyers, and other Texas
Medicare and Medicaid Billing Fraud
Lawyers as well as with Medicare Billing Fraud Lawyers throughout the
nation to blow the whistle on fraud that hurts the United
States.
If you are a Medicare Compliance
Manager, Medicare Reimbursement Manager, Medicare Coding
Manager, health care administrator, or other health care
professional with original source knowledge of Medicare
Billing Fraud or
Hospital Medicare Billing Fraud, it is important
that you are the first to step forward to blow the
whistle on the Medicare Billing fraud. If you are a
Medicare Billing Fraud Whistleblower that is aware of
fraudulent Medicaid billing scam, Medicare kickbacks,
Medicaid kickbacks or other Medicare billing fraud
scams, feel free to
contact Medicare Billing Fraud Whistleblower Lawyer
Jason Coomer via e-mail message or our
submission form.
