Medicare fraud and Medicaid fraud are becoming the fastest growing and most lucrative crimes in the United States. It is estimated that Medicare fraud and Medicaid fraud costs tax payers between $70 Billion and $230 Billion each year. As such, the United States Department of Justice and Texas Medicare Fraud Lawyer, Jason S. Coomer, are encouraging Medicare Fraud Whistleblowers with evidence of systematic Medicare fraud or systematic Medicaid fraud to step up and blow the whistle on Medicare fraud and Medicaid. For more information on a being a Medicare Fraud Whistleblower or Medicaid Fraud Whistleblower that could be entitled to a large recovery for exposing systematic Medicare Fraud or Medicaid Fraud, feel free to contact Medicare Fraud Lawyer Jason Coomer via e-mail message or use our submission form.
Many Large "For Profit" Health Care Providers
Become Medical Assembly Lines for Patients, Provide Mass
One Size Fits All Medical Services for Patients
Regardless of Individual Medical Need, and Commit
Systematic Medicare Fraud and/or Medicaid Fraud
by Texas Medicare Fraud Lawyer Jason S. Coomer
In the modern age of medicine, large "for profit" health care providers have turned traditional medical practices where doctors knew their patients and were able to spend significant time with their patients into large "for profit" billing machines where many patients are run through an assembly line where the patient is lucky to spend 10 or 15 minutes with a doctor. These "for profit" patient mills often tend to provide one size fits all services despite the individual needs of the patient. In many of these large "for profit" medical systems, patients are nothing more than a number or a Medicare number that can be billed.
The large "for profit" hospitals and health care systems, often view patients through their billing departments as ways to make a profit by billing for expensive and unnecessary services as long as the services can be billed to the person's Medicare number. Regardless of the patient's actual needs, the ability to bill Medicare for services becomes a driving force as to how the person is treated in the medical system. By maximizing the amount that can be billed to Medicare or other third party payers, the large health care provider is able to maximize their revenue and profits regardless of what the patient actually needs. The patient's needs often become secondary to the need to maximize profits.
The need to overcome an economic incentive that could turn medical providers away from the best interests of patients was understood and the basis in passing the Stark Laws and Anti-kickback Laws. Hopefully, new whistleblower protections and expanded False Claims Act laws may also help curb negative economic incentives and profit driven health care providers that are placing profits over the needs of patients.
In situations where the health care provider is driven by profit instead of a patient's needs, the traditional doctor patient relationship is violated. The patient's trust in the health care provider can then often be misplaced. Where the traditional expert advice of a medical doctor was once in the patient's best interest, the "for profit" health care provider can now be working against a patient's best interest and to only be maximizing profits.
Further, many "for profit" health care providers have separate billing departments, accountants, and administrators whose jobs are to maximize the hospital or health care system's profits. These billing departments, accountants, and administrators, can sometimes determine that by making systematic changes including upcoding, phantom billing, or other Medicare fraud, that the hospital's or health care system's monthly, quarterly, or annual profits can be increased. By slowly and continually making these systematic Medicare fraud changes, the hospital can continue to increase profits and the incremental changes can be extremely hard to detect.
Hospital Medicare Fraud Whistleblower
Lawyer, Nursing Home Medicare Fraud Whistleblower
Lawyer, Physician Medicare Fraud Whistleblower
Lawyer, Hospice Fraud Whistleblower Lawyer, and Home
Health Care Medicare Fraud Whistleblower Lawyer
(Medicare Fraud Whistleblower Law Suits)
If you are a hospital administrator, nursing home administrator, physician, nurse, respiratory therapist, coder, accountant, dentist, health care coordinator, coding specialist, or other health care professional that is aware of Medicare fraud, it is important that you report the Medicare fraud. As a Medicare fraud whistleblower you not only can recover a portion of the recovery if the fraud is properly reported, but it can help avoid potential criminal liability. Medicare fraud lawyer, Jason S. Coomer helps whistleblowers that are aware of systematic Medicare fraud including health care providers that are committing upcoding, illegal kickbacks, charging for unnecessary services and procedures, charging for services not provided, double billing, or bill padding, feel free to contact Medicare Fraud Lawyer, Jason Coomer with any questions that you might have.
Medicare Fraud Lawsuit, Systematic Medicare
Fraud Lawsuit, Medicare Recipient Whistleblower Lawsuit,
Medicare Fraud Whistleblower Lawsuit, Systematic
Medicaid Fraud Lawsuit, and Medicare Compliance Fraud
by Texas Medicare Fraud Lawyer Jason S. Coomer
Medicare fraud and Medicaid fraud scams are costing the United States hundreds of billions of dollars and are threatening the Medicare benefits and Medicaid benefits of millions of Americans. The cost of systematic Medicare fraud and systematic Medicaid fraud includes nursing homes, home health care services, hospitals, therapists, dentists, and other health care providers that systematically and knowingly commit upcoding Medicare fraud schemes, double billing Medicare fraud schemes, unnecessary service Medicare Fraud schemes, and other fraudulent Medicare billing schemes. By billing for services not provided or needed, many fraudulent health care providers have found it extremely profitable to exploit the current Medicare and Medicaid system.
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 through economic incentives to step up and blow the whistle on significant Medicare Fraud and Medicaid Fraud. Medicare Fraud Whistleblowers and Medicaid Fraud Whistleblowers that are the original source of specialized knowledge of significant Medicare Fraud or systematic Medicaid Fraud can make substantial recoveries if they are the first to file a successful qui tam claim under the Federal False Claims Act.
If you have evidence of significant systematic Medicare Fraud or systematic Medicaid Fraud, it is important that you properly report that the systematic Medicare fraud or systematic Medicaid fraud, so that you can potentially recover a portion of the money recovered from the fraudulent health care provider.
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 hospital administrators, doctors, nurses, accountings, coders, billing specials, compliance specialist, and other health care professionals to have specialized knowledge of Medicare fraud, systematic Medicare Fraud, and fraudulent Medicare schemes. As such, it is important for the systematic Medicare fraud whistleblowers to obtain and preserve evidence of the Medicare 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 systematic Medicare fraud. It is also often helpful to have fellow whistleblowers that can help build the Medicare Fraud or systematic Medicare 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 Fraud Scams, Medicare Reimbursement Fraud Scams, Systematic Medicare Fraud Scams, and Medicare Fraud Kickback Scams
It is also essential to not delay in coming forward with a False Claim Act Medicare Fraud Whistleblower 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 Fraud Lawsuit Information, Texas Medicare Fraud Whistleblower Lawsuit Information, Texas False Medicare Billing Lawsuit Information, Medicare Coding Fraud Whistleblower Lawsuit Information, and Medicare Compliance Fraud Lawsuit Information by Texas Medicare Fraud Lawyer
Texas Medicare Fraud Lawyer, Jason S. Coomer, is working with Medicare Fraud Whistleblowers to expose Medicare fraud and blow the whistle on criminals that are fraudulently stealing from the United States and the Medicare program.
Below are several press releases regarding Medicare Fraud.
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.
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
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.
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.
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Medicare Recipient Whistleblowers may also be a relator that discovers systematic Medicare fraud and receive a large Medicare fraud whistleblower recovery from the government. The Medicare recipient must 1) obtain original and specialized information of significant fraud and 2) be the first to file regarding the specific Medicare fraud to recover a large reward for reporting the fraud. Follow this link for Medicare Recipient Whistleblower Lawsuit Information.
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.
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Health care companies that are committing Medicare fraud scams are being brought to justice by whistleblowers and law enforcement. Medicare Fraud Lawyer Jason Coomer is working with other powerful Medicare fraud lawyers to help Medicare fraud whistleblowers blow the whistle on systematic Medicare fraud. He works with San Antonio Medicare Fraud Lawyers, Dallas Medicare Fraud Lawyers, Houston Medicare Fraud Lawyers, El Paso Medicare Fraud Lawyers, and other Texas Medicare Fraud Lawyers as well as with Medicare Fraud Lawyers throughout the nation to blow the whistle on fraud that hurts the United States.
If you are aware of systematic Medicare fraud and are the original source knowledge of Medicare Fraud, it is important that you are the first to step forward to blow the whistle on the systematic Medicare fraud. If you are a Medicare Fraud Whistleblower that has evidence of a fraudulent Medicaid billing scam, a Medicare kickback scam, Medicaid kickbacks, or other systematic Medicare fraud, feel free to contact Medicare Fraud Lawyer Jason Coomer via e-mail message or our submission form.