The following is a summary of selected federal Department of Health and Human Services’ Office of Inspector General (OIG) reports of fraud and abuse enforcement activity across the country.[1] The enforcement actions reported are based upon federal and individual states’ activity reported by OIG through its listserv on Enforcement Actions.
The summaries reflect areas of OIG’s and individual states’ current and recent enforcement activity.[2] Knowing where regulators’ attention is focused helps healthcare providers identify areas of attention for compliance and risk assessment activities. Although not all the enforcement actions may be relevant to any one provider’s health care business, there may be some summaries that could be used as examples in compliance education programs (“What to avoid”), or used in developing a risk management plan. (Note: An Acronym Key appears at the end of the Report.)
Of Note in this Issue:
- LinCare settles claims for overbilling Medicare and Medicare Advantage for oxygen equipment rentals and agrees to refund overpayments and repay Medicare beneficiaries’ copayments associated with the overpayments. (August 30, 2023).
- Physician, operator of a clinic, allegedly required patients to visit the clinic as many as six times per month and receive steroid injections as a condition of issuing patients their prescriptions. It was also alleged the physician altered progress notes to justify higher billing rates. (August 28, 2023).
- Sonography company allegedly entered into a sublease with physicians and paid excessive rent to induce referrals from the physicians who were subleasing the space to the sonography company. The defendant entered into a Deferred Prosecution Agreement. (August 21, 2023).
- Dentist, hired by excluded dentist, pled guilty to fraud and conspiracy to commit fraud, when he allegedly allowed the excluded dentist to provide services and then billed Medicaid for those services, paying a portion of the proceeds to the excluded dentist. (August 11, 2023).
- Department of Justice obtains its first conviction of a physician for healthcare fraud in billing for office visits in connection with patients seeking COVID-19 tests. (August 7, 2023).
- Healthcare system obtained higher risk-adjusted payments when it submitted inaccurate diagnosis codes that reflected higher risk scores for Medicare Advantage beneficiaries than were supported by the medical records. (August 1, 2023).
- Not included in the summaries below are reports on enforcement investigations and actions by federal Task Forces deployed to address Fraud, Waste and Abuse related to the COVID-19 pandemic and various federal government programs initiated to provide pandemic relief. The programs included in the Task Force work include Paycheck Protection Program (“PPP”) and Economic Injury Disaster Loans (“EIDL”) Fraud, Unemployment Insurance Fraud, and COVID-19 CARES Act, as well as COVID-19-related fraud schemes, related to payment for COVID-19 treatment or testing.
August 31, 2023 OIG Listserv Release
Somers Man Pleads Guilty to Charge Stemming from Medicaid Fraud Scheme
CT. The Defendant, a licensed alcohol and drug abuse counselor, agreed with a medical provider to use Defendant’s provider number to bill Medicaid for the medical provider’s alleged psychotherapy sessions with patients. The Defendant retained 25% of the Medicaid payments and paid 75% of the payments to the medical provider. Medicaid billings reflected that the Defendant performed psychotherapy and related services when they were not personally performed by the Defendant, who never met the medical provider’s clients and did not review records and treatment notes for any services allegedly rendered by the medical provider.{Editor’s note: There was no indication in the report if the “medical provider” initiated the alleged scheme as a result of a sanction or loss of license.}
Health Care Provider Agrees to Pay $5 Million for Alleged False Claims to California’s Medicaid Program
and
Central Coast Health Care Provider Agrees to Pay $5 Million for Alleged False Claims to California’s Medicaid Program
CA. The Defendant, a healthcare district operating multiple healthcare providers, settled allegations that it violated the federal and CA FCAs related to the Medicaid Adult Expansion under the Patient Protection and Affordable Care Act (ACA). It is alleged that the Defendant knowingly submitted false claims for enhanced services that were not allowed medical expenses under the program, were pre-determined amounts that did not reflect the FMV of the services under the program; and/or the enhanced services were duplicative of services already required to be provided.
This matter was initiated through a Qui Tam complaint.
August 30, 2023 OIG Listserv Release
Lincare Holdings Agrees to Pay $29 Million to Resolve Claims of Overbilling Medicare for Oxygen Equipment in Largest-Ever Health Care Fraud Settlement in Eastern Washington
WA. The Defendant allegedly overbilled Medicare and Medicare Advantage Plans for oxygen equipment that was leased and when Medicare lease maximums were reached after three years, Defendant continued to charge rent on the equipment and charge patient copayments which were not allowed under MA programs. The Defendant admitted that it continued rental fees and charged copayments after it received 3 years of payments; it admitted that the controls in place to prevent improper billing were not always effective; and it admitted that when employees raised questions about the Defendant’s billing practices, the Defendant’s corporate headquarters instructed that it would continue its billing practices. The Defendant will be under a 5-year Corporate Integrity Agreement, it will refund overpayments to Medicare, and it will identify and repay improperly collected copayments from beneficiaries.
This matter was initiated through a Qui Tam complaint.
August 28, 2023 OIG Listserv Release
Clarksville Doctor Sentenced in Health Care Fraud Case – Medicare Billed $1,885,245 for Unnecessary and Overbilled Office Visits
TN. The Defendant, a physician and operator of a clinic, allegedly required Medicare beneficiaries to visit his clinic as many as six times each month and to undergo unnecessary steroid injections in order to obtain their prescriptions. Evidence presented at trial also included that the Defendant altered progress visit notes in patient records to justify higher billing rates.
Greenville Woman Pleads Guilty to Making Fraudulent Statements to Medicaid in Connection with the Delivery of Autism Spectrum Disorder Services
SC. The Defendant, owner of a provider using Applied Behavior Analysis therapy to treat Autism Spectrum Disorder, pled guilty to submitting electronic claims to Medicaid and fraudulently certifying that services had been rendered and/or certifying that services had been rendered in excess of what was actually provided to beneficiaries.
August 25, 2023 OIG Listserv Release
Attorney General Bonta Announces Sentencing of Southern California Doctor for Medi-Cal Fraud
CA. The Defendant, a physician, pled guilty to allegations of prescribing medically unnecessary HIV medications and anti-psychotics for Medi-Cal beneficiaries. As the prescriber at two clinics, the Defendant carried out an alleged prescription scheme where, in exchange for cash payments, he prescribed expensive and medically unnecessary medications to Medi-Cal beneficiaries who then diverted the medications to illicit market for cash.
Michigan Doctor to Pay $6.5 million to Resolve False Claims Act Allegations
MI. The Defendants, a physician and his two medical entities, agreed to resolve allegations that Defendants billed Medicare and Medicaid for excessive and medically unnecessary presumptive and definitive urine drug tests that were not relevant to patients’ diagnoses or treatment and for lab charges that were not separately billable with urine drug tests. Additional allegations included that Defendants billed Medicare and Medicaid for medically unnecessary moderate sedation services routinely performed in conjunction with interventional pain management procedures that did not require moderate sedation. Also alleged was that the Defendants billed for expensive back braces that were medically unnecessary or otherwise ineligible for reimbursement.
The matter was initiated through a Qui Tam action.
August 23, 2023 OIG Listserv Release
Florida Man Admits $3.6 Million Health Care Fraud Scheme
NJ. The Defendant pled guilty to receiving kickbacks and bribes when he and his conspirators allegedly provided DME companies with completed doctors’ orders for medically unnecessary DME. The Defendant allegedly used telemedicine companies to obtain the DME prescriptions, which were then used to fraudulently bill Medicare. The Defendant allegedly received kickbacks on those medically unnecessary DME orders.
August 21, 2023 OIG Listserv Release
Morris County Sonography Company Enters into Deferred Prosecution Agreement, Agrees to Pay $95,000 to Settle Kickback Allegations
NJ. The Defendant, a sonography company, allegedly agreed to pay rent in excess of the reasonable value to physicians to induce the physicians to refer patients for diagnostic testing to the Defendant when it paid for significantly more hours than the Defendant’s technicians actually used in the subleased space. The sublease rent paid by the Defendant was allegedly more than the rent paid by the physicians and after the Defendant began making its payments, the physicians in receipt of those payments began to refer patients to the Defendant for diagnostic tests that were then billed to Medicare. It is alleged that the sublease rent rate was commercially unreasonable and was for the purpose of inducing diagnostic testing in violation of the federal AKS.
The matter was initiated through a Qui Tam action.
Former Pharmacy President Admits $32 Million Health Care Kickback Scheme
NJ. The Defendant pled guilty to conspiracy to pay marketing companies to direct prescriptions for expensive medication to his pharmacies. It is alleged that the marketing companies contacted beneficiaries to target for expensive drugs and used telephone pressure to get the beneficiaries to agree to try expensive medications. The marketing companies provided the telephone recordings together with pre-marked prescription pads for particular drugs to telemedicine companies. Kickbacks were allegedly paid by the marketers to the telemedicine companies for every beneficiary referred for a prescription and the telemedicine companies allegedly paid doctors to approve the prescriptions. The marketing companies allegedly directed the prescriptions to pharmacies, including the Defendant’s pharmacies, with which a kickback agreement was in place. A portion of the government program payments for the prescription reimbursement was allegedly paid as a kickback.
Pharmacy Operations Manager Admits Role in Multimillion-Dollar Health Care Fraud and Kickback Scheme
NJ. The Defendant, a former operations manager of a specialty pharmacy, pled guilty to conspiracy to commit health care fraud and to violating the federal AKS. Allegations include that, under retail network agreements the specialty pharmacy had with several PBMs, it received payments for prescription medicines, including specialty medications. It is alleged that bribes were paid to doctors and doctors’ employees to induce those offices to steer prescriptions to the specialty pharmacy where Defendant worked. Health insurers were allegedly billed for medications that were never provided to patients through systematic billing for refills without ever dispensing them to patients; and for medications that were never ordered or in stock at the pharmacy. When PBMs were conducting audits, the specialty pharmacy allegedly directed employees to falsify records submitted to the PBMs and used forged shipping records to make it appear that medications were shipped to patients when they were not. Charges against other conspirators are pending.
Lab Owner Sentenced for $463M Genetic Testing Scheme
GA. The Defendant, owner of a lab, allegedly conspired with patient brokers, telemedicine companies, and call centers to target Medicare beneficiaries with telemarketing calls falsely stating that Medicare covered expensive cancer genetic tests. After beneficiaries agreed to take a test, the Defendant allegedly paid kickbacks and bribes to patient brokers to obtain signed doctor’s orders authorizing the tests from telemedicine companies who the Defendant knew provided the doctor’s orders which were not based on treatment of beneficiaries, who were often not seen, and where no evaluation of medical necessity was made. Kickbacks and bribes were allegedly concealed through patient brokers signing sham contracts that falsely stated the brokers were performing legitimate advertising services for the Defendant’s lab.
August 18, 2023 OIG Listserv Release
Attorney General Josh Stein Announces Sentencing in $4 Million Health Care Fraud
NC. See article from August 11, 2023, on Federal announcement under heading below of Pharmacy Owner and Technician Both Sentenced to Prison for Health Care Fraud
Destrehan Man Pleads Guilty to $11.4 Million Medicare and Medicaid Fraud Scheme
LA. The Defendant, through his DME company, allegedly billed Medicare and Medicaid for DME that was medically unnecessary, not ordered, or not provided as represented. In some cases, claims were submitted for patients who had died. To cover up the scheme, the Defendant directed the falsification of documents, including medical records, order forms, and supporting documentation, in response to Medicare audits and record requests. The falsification included forging provider signatures, medical notes and dates, as well as using tape, white-out, and scissors to make it falsely appear that the DME was ordered and delivered.
Former Southeastern Connecticut Counselor Pleads Guilty to Health Care Fraud and Kickback Charges
CT. The Defendant, a Licensed Professional Counselor (LPC), pled guilty to healthcare fraud and violation of the federal AKS when, after being advised that Medicaid was going to recoup $225,000 from future payments to the Defendant, he began submitting fraudulent claims to Medicaid for psychotherapy services that were never provided. The Defendant admitted that he engaged in a scheme to pay kickbacks to his Medicaid patients to induce them to receive psychotherapy services from him. Kickbacks were paid in the form of cash, money orders, and gift cards.
August 17, 2023 OIG Listserv Release
After a Six-Day Trial, Federal Jury Convicts Holy Health Care Services, LLC Program Administrator for a Health Care Fraud Scheme
MD. The Defendant, a program administrator at a mental health services provider servicing Medicaid, was convicted of conspiracy to commit healthcare fraud, wire fraud, and conspiracy to make false statements in a scheme to fraudulently bill Medicaid. The Defendant and co-conspirators allegedly paid individuals to come into the office and then the Defendant used personally identifiable information to bill Medicaid for services that were not rendered or were not rendered as billed. The Defendant made up “fake” employees who were purportedly community support workers (CSW) that could bill Medicaid and the Defendant billed Medicaid for services for the fake employees. Undercover investigators confirmed they did not receive the services as billed; nevertheless, the mental health provider billed for CSW services for patient visits that never happened.
The owners of the mental health services provider had previously pled guilty to conspiracy to commit healthcare fraud in connection with a scheme to pay bribes and kickbacks to Medicaid beneficiaries to entice them to visit their company.
Florida Business Owner Sentenced To Five Years In Prison For Defrauding Medicare Of More Than $11 Million
NY. The Defendant was sentenced for conspiring to defraud Medicare in a scheme to pay and receive kickbacks in connection with illegally buying and selling signed orders for DME, and then using those orders to file fraudulent Medicare claims, as well as selling the orders to other DME supply companies so those companies could also file fraudulent Medicare claims. Some DME orders contained signatures of doctors who said they never signed or authorized the orders and were unaware their names and identities were being used.
August 16, 2023 OIG Listserv Release
Air Medical Transport Company Agrees to Pay $1 Million to Resolve Allegations of False Claims Act Violations
KY. The Defendant, a national provider of air medical transportation services, settled allegations that it failed to return known overpayments for 100 flights it knew to be medically unnecessary. Allegations included that the Defendant violated the FCA when its own internal review process identified the flights that did not meet Medicare, Medicaid, Tricare and VA requirements and the Defendant did not return the known overpayment.
The matter was initiated through a Qui Tam action.
August 15, 2023 OIG Listserv Release
Pittsburgh Resident Sentenced to 18 Months of Imprisonment for Convictions of Agreeing with Others to Pay Illegal Kickbacks Related to Laboratory Tests
PA. The Defendant, an owner and operator of clinical laboratories, allegedly paid illegal kickbacks to marketers in return for the marketers obtaining cheek swabs from Medicare beneficiaries to be used in lab testing. The Defendant also paid kickbacks to ensure telemedicine physicians provided prescriptions for lab testing of the swabs obtained by the marketers, which the Defendant billed for the performance of the tests.
August 14, 2023 OIG Listserv Release
Four East Tennessee Doctors Convicted in Drug Trafficking and Fraud Scheme
KY. The Defendants worked together in two Tennessee clinics that purported to offer treatment for opioid use disorder. The opioids prescribed by the Defendants allegedly were sold, traded and abused for cash in KY. The Defendants allegedly conspired to falsify medical records while allegedly treating patients. Some Defendants were alleged to have submitted fraudulent claims to Medicare, Medicaid and other healthcare programs for prescription drugs and urine testing.
Outside the scope of this summary are the DEA allegations.
August 11, 2023 OIG Listserv Release
Attorney General Josh Stein Announces $1.9 Million Medicaid Settlement with Cary Lab
NC. The Defendants, a lab and its owner, settled allegations that the Defendants billed Medicaid for unnecessary urine drug tests and paid illegal kickbacks for the tests. The Defendants allegedly paid two companies for each urine drug test referred to the Defendant lab. The tests allegedly were medically unnecessary, were not patient-specific, and did not reflect an appropriate determination of the patient’s need for the tests.
Office of the Attorney General’s Civil Medicaid Fraud Division Recovers $42.7 Million in Taxpayer Funds
TX. A settlement was reached with three pharmaceutical drug manufacturers to resolve allegations that the manufacturers provided, directly or indirectly, nursing and reimbursement services to Medicaid providers for certain pharmaceutical drugs, as well as paying clinical nurse educators to refer or recommend the drug Vyvanse to providers. Their actions allegedly violated the Texas Medicaid Fraud Prevention Act.
The matter was initiated through a Qui Tam action.
Attorney General Tong Announces $470,000 Settlement with Optimus Health Care Over False Claims and Improper Billing Allegations
CT. See article from August 10, 2023, on Federal announcement under heading below of Federally-Qualified Health Center Pays $470K to Settle False Claims and Improper Billing Allegations.
Chelmsford Dentist Sentenced to More Than a Year in Prison for Medicaid Fraud Scheme
MA. The Defendant, a dentist, pled guilty to conspiring to commit health care fraud and health care fraud. The Defendant was hired by a dentist excluded from MassHealth and when the excluded dentist performed dental services, it is alleged those services were billed as being performed by the Defendant. The Defendant allegedly paid the excluded dentist a share of the money received from MassHealth. The excluded dentist was barred from participation in MassHealth due to concerns regarding the quality of dental care being provided to patients.
Pharmacy Owner and Technician Both Sentenced to Prison for Health Care Fraud
NC. The Defendants, owner and tech at a pharmacy, pled guilty to allegedly billing Medicare and Medicaid and commercial payors for prescription drugs that were not authorized or dispensed. Pharmacy employees were also allegedly trained to falsely reauthorize a previously existing prescription from a licensed medical professional and to falsely bill healthcare programs as though a drug had been dispensed.
August 10, 2023 OIG Listserv Release
Neuroscience Company and Co-Founder/CEO Pay $445,000 to Resolve False Claims Act Allegations Related to Promotion of False Billing Codes
PA. The Defendants, Evoke Neuroscience, Inc. of New York and its CEO, David Hagedorn, Ph.D., allegedly violated the FCA by promoting false billing codes for a “brain health” device. Dr. Hagedorn allegedly promoted six false Medicare billing codes for the device’s use by health care providers that the United States contends were not appropriate , since the codes generally require a longer testing time, a specialized treatment environment, and can only be administered by a relevant specialist. The Defendants also allegedly improperly encouraged providers to bill multiple codes for a single application of the device, despite coding consultants informing Evoke that the billing codes being promoted were problematic, after which Evoke stopped promoting the false codes.
The matter was initiated through a Qui Tam action.
Federally-Qualified Health Center Pays $470K to Settle False Claims and Improper Billing Allegations
CT. The Defendant, an FQHC, allegedly submitted false claims to CT Medicaid for dual-eligible beneficiaries using incorrect Medicare denial codes, causing Medicaid to pay claims it would otherwise deny as Medicare was primary. Additionally the Defendant allegedly billed Medicaid for group therapy services for Qualified Medicare Beneficiaries who were not eligible for Medicaid reimbursement for those services. (A “QMB” qualifies for Medicaid to pay their Medicare copayments, premiums, coinsurance and deductibles.)
The matter was initiated through a Qui Tam action.
August 7, 2023 OIG Listserv Release
North Carolina Laboratory And Owner Agree To Pay More Than $1.9 Million To Resolve False Claims Act Allegations
NC. The Defendants, an owner and his lab, allegedly submitted claims to Medicaid for urine drug tests that were part of illegal kickback arrangements between the lab and the entities referring the urine drug tests. The Defendants paid the referring entities for each drug test referred to the Defendants. Additionally, it is alleged the tests were medically unnecessary because orders for the tests billed by the Defendants were not patient-specific and did not reflect a qualified medical provider’s determination of the patients’ need for the testing.
Doctor Convicted for COVID-19 Health Care Fraud Scheme
and
Maryland Doctor Convicted After Three-Week Trial for COVID-19 Healthcare Fraud Scheme
MD. The Defendant, a physician owner and medical director of multiple drive-through COVID-19 testing sites, instructed employees that, in addition to billing for COVID-19 tests, they were to bill for high-level evaluation and management visits, which were not provided to patients as represented. The Defendant also allegedly told employees that patients were there for testing only and not to address complex medical issues. The high-level visits were billed for all patients, including those who were asymptomatic and getting tested for COVID for employment requirements or to travel.
It is reported that this case is the first Department of Justice case where a doctor was convicted at trial for healthcare billing fraud for office visits connected to patients seeking COVID-19 tests.
August 4, 2023 OIG Listserv Release
Texas Attorney General’s Medicaid Fraud Control Unit Helps Secure 49-Month Sentence and Over $5 Million Restitution in Orthopedic Supplies Fraud Case
TX. The Defendant, a co-owner of a DME business, allegedly obtained patients by offering and paying kickbacks to marketers and disguised those illegal payments as marketing services and outsourced business services. False claims were allegedly submitted to Medicaid and Medicare for orthopedic equipment that was never provided, not medically necessary, and not authorized by a physician.
AG Campbell Reaches $2.6M Settlement With Leominster-Based Ambulance Company, MedStar, To Resolve False Billing Allegations
MA. The Defendant, a medical transportation provider and its parent and affiliates, allegedly submitted false claims to Medicaid for emergency ambulance services when a less expensive nonemergency level of service was provided. The Defendant allegedly provided nonemergency ambulance services or wheelchair van services without appropriate medical necessity documentation and then submitted claims to Medicaid without showing the appropriate medical necessity documentation to the authorized provider who was signing it.
Former Charlotte Housing Provider Is Sentenced To Prison For Medicaid Fraud And Money Laundering Conspiracy
NC. The Defendant, a subsidized housing provider, conspired with the owner and operator of a urine toxicology testing lab and with a company providing mental health and substance abuse treatment services, , to submit urine specimens for drug testing as a condition of participation in the Defendant’s program. The samples provided were alleged to be medically unnecessary. The Defendant was allegedly paid a kickback from the Medicaid reimbursements and the Defendant also conspired with the lab owner to launder the fraudulent proceeds to conceal and disguise the nature and source of the illegal kickback payments for the medically unnecessary drug testing referrals.
Former CEO of Whittier Clinic Pleads Guilty to Defrauding Medi-Cal Family Planning Program Through Multimillion-Dollar Scheme
CA. The Defendant allegedly used a non-profit clinic to submit fraudulent claims for family planning services that were never provided, often using the information of patients who were recruited at off-site locations with offers of free diabetes testing, but who never received the examinations and other services. In submitting many claims, he used two medical providers who patients did not see and who did not work for the clinic. Additional claims to Medicaid were submitted for pharmacy and lab services stemming from referrals based on services that were allegedly not delivered.
Former Employee of Eye For Change Youth and Family Services Found Guilty of Fraudulent Medicaid Billing Practices
OH. The Defendant allegedly cause Medicaid to be billed for services not actually performed or for services that were not actually performed for the amount of time the billing codes reflected, for falsifying progress notes in Medicaid beneficiary electronic records, for creating false progress notes, and for using the identities of clients without authorization to bill Medicaid.
August 2, 2023 OIG Listserv Release
Northeast Philadelphia Pharmacies and Their Owners Agree to Pay Over $3.5 Million to Resolve False Claims Act Liability
PA. The Defendants, pharmacies and their owners, allegedly violated the FCA by billing Medicare for prescription medications that were not actually dispensed. The majority owner is also alleged to have violated the Controlled Substances Act. The allegations related to the Controlled Substances Act are outside the scope of this summary.
Clinical Laboratory and Its Owner Agree to Pay an Additional $5.7 Million to Resolve Outstanding Judgement for Billing Medicare for Inflated Mileage-Based Lab Technician Travel Allowance Fees
TX. The Defendants, a clinical lab and its owner, allegedly billed false claims to Medicare when the clinic knowingly billed for travel allowance reimbursements that did not reflect the actual mileage the lab technicians traveled when specimens were collected from nursing home residents.
The matter was initiated through a Qui Tam action and the settlement is intended to resolve outstanding obligations under a 2018 judgement.
August 1, 2023 OIG Listserv Release
Pain Clinic Owner, L5 Medical Holdings Plead Guilty- Agree to Pay $4 Million in Restitution
VA. The Defendants – an owner with no medical background and his holding company that owned pain management clinics, allegedly operated the pain management clinics with a focus on prescribing opioids rather than interventional treatments. Providers were encouraged to limit patient visits to 15 minutes and see up to 30 patients per day. Medical providers were directed to follow the opinions of non-medical professionals in making treatment decisions for opioid addition for pain management, whether patients should receive a prescription and what drug should be prescribed. Patient interactions with non-medical professionals were improperly billed to Medicaid and Medicare. Urine drug screening policy was implemented based on insurance reimbursement rather than patient care. The Defendants allegedly refused to implement a random drug screening policy so they would not lose the Medicare and Medicaid revenue for as many drug tests those policies would cover.
Missouri Laboratory Owners Agree to Pay $1.9 Million and Relinquish $7 Million in Escrow in Settlement of Civil Fraud Claims
MO. The Defendants, owners of a clinical testing lab, settled allegations that the lab billed for tests that were not medically necessary. The Defendants allegedly represented to medical providers that its upper respiratory infection and urinary tract infection polymerase chain reaction testing panels were reasonable and medically necessary. Forms used by the Defendants did not allow for medical providers to make independent medical necessity decisions about each lab test ordered. The Defendants’ lab panels included tests for pathogens that lacked a common symptomology to support a payment.
Additional allegations included that the Defendants continued to submit claims for payment even after Medicare began rejecting certain billing codes and, in an alleged attempt to circumvent Medicare rejections, the Defendants selected other billing codes. Additional allegations were that false claims were submitted for therapeutic drug assays and specimen validity testing using certain CPT codes at the same time claims were submitted for reimbursement using a different code that incorporates some of the same tests.
Martin’s Point Health Care Inc. to Pay $22,485,000 to Resolve False Claims Act Allegations
ME. The Defendant allegedly violated the FCA by intentionally submitting inaccurate or additional diagnosis codes to reflect higher risk scores for Medicare Advantage patients than were supported in beneficiaries’ medical records. The higher risk scores resulted in higher risk-adjusted payments to the Defendant from Medicare Advantage plans.
The matter was initiated through a Qui Tam action.
CORPORATE INTEGRITY AGREEMENTS – NEW CASES
None published in August.
Key:
AG = Attorney General
AKS = Anti-Kickback Statute
CIA = Corporate Integrity Agreement
CMP = Civil Monetary Penalties
CMS = Centers for Medicare and Medicaid Services
CPT = Current Procedural Terminology Codes
DME = Durable Medical Equipment
E&M = Evaluation & Management services
FEHBP = Federal Employees Health Benefits Program
FMV = Fair Market Value
DOJ = United States Department of Justice
FCA = False Claims Act
FWA = Fraud, Waste & Abuse
HHS = Department of Health and Human Services
HRSA = HHS’s Health Resources and Services Administration
IA = Integrity Agreement
LTC = Long Term Care (usually facilities)
MA = Medicare Advantage Program
MCO = Managed Care Organization (typically Medicaid)
MFCU = Medicaid Fraud Control Unit
MSO = Management Services Organization
NH = Nursing Home
NPI = National Provider Identifier
OIG = Office of Inspector General in HHS
OT = Occupational Therapy
PBM = Pharmacy Benefit Managers
PT = Physical Therapy
SNF = Skilled Nursing Facility
[1] Not included in the summaries are prosecutions related solely to drug diversion and inappropriate prescriptions, patient fiscal or physical abuse, or non-healthcare related matters such as misuse of COVID-19 relief funds. The summaries also do not include enforcement announcements of arrests with no report of an indictment or civil complaint.
[2] The summaries should be considered to reflect allegations and not necessarily be considered to be statements of fact.
