Category Archives: Fraud & Abuse & False Claims Act

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Medicare Fraud Strike Force Strikes Again – in a Big Way

The Medicare Fraud Strike Force initiated its largest ever healthcare enforcement action, charging 412 defendants in July 2017 with approximately $1.3 billion in fraudulent claims. The Strike Force consists of teams that include the Office of Inspector General, the Department of Justice, Offices of the United States Attorneys, the Federal Bureau of Investigation, and local law enforcement, with efforts concentrated … Continue Reading

Former Home Health Agency Owner Sentenced to 20 Years for $57MM Medicare Fraud

The US Department of Justice announced that Khaled Elbeblaswy, the former owner and manager three Miami-area home health agencies, was sentenced to 20 years in prison and ordered to pay $36.4 million in restitution for his role in a $57 million Medicare fraud scheme.… Continue Reading

What does the Escobar Decision Mean for Healthcare Providers?

Universal Health Services, Inc. v U.S. ex rel. Escobar

On June 16, 2016, the U.S. Supreme Court in Universal Health Servs., Inc. v. United States ex rel Escobar, No. 13-317, — S. Ct. — (June 16, 2016), confirmed that the implied certification theory may serve as a basis for liability under the False Claims Act (FCA), although it employed … Continue Reading

New CMS rule clarifies when 60-day overpayment clock starts ticking

Four years after publication of its proposed rule related to reporting and returning overpayments within 60 days, CMS has issued a final rule that responds to comments and provides greater clarity. The published rule is under the Affordable Care Act requirement that providers report Medicare and Medicaid overpayments and return the overpayment within 60 days of the date it was … Continue Reading

Identifying Overpayments Under the ACA’s 60-Day Rule Creates Additional Uncertainty in Determining False Claims Act Liability

Under the Affordable Care Act (ACA), healthcare providers that receive an overpayment from Medicare or Medicaid are required to report and return the overpayment to the government within 60 days after the date on which the overpayment was identified (commonly referred to as the “60-day rule”). An overpayment retained after 60 days constitutes an “obligation” for purposes of potential False … Continue Reading

OIG Issues Favorable Opinion Giving Green Light To Health System’s Shuttle Service

The Office of Inspector General (OIG) recently issued another advisory opinion on free patient transportation (OIG Adv. Op. No. 15-13, dated October 21, 2015). In the opinion, the OIG addresses whether providing patients a free shuttle service between medical facilities operated by an integrated health system (the System) would be prohibited remuneration to beneficiaries under the Anti-Kickback Statute. … Continue Reading

OIG Now Targeting Physician Compensation Arrangements

In a Fraud Alert issued on June 9, 2015, the U.S. Department of Health and Human Services Office of Inspector General (OIG) notified the healthcare community that physician compensation arrangements are on the OIG’s radar screen. While many physician compensation arrangements may be legitimate, the OIG has noted that “a compensation arrangement may violate the anti-kickback statute if even one … Continue Reading

What Is Your Fraud Rank?

On June 2, 2015, Center for Medicare & Medicaid Services (CMS), provided direction to state Medicaid Directors on the implementation of Section 6401 of the Affordable Care Act, Provider Screening and Other Enrollment Requirements under Medicare, Medicaid and the Children’s Health Insurance Program (CHIP).… Continue Reading

Court Allows Counterclaim Against Whistleblower for Breach of Employment Agreement

A federal court in New Jersey has permitted a defendant in a False Claims case to defend itself on the grounds that the whistleblower/ex-employees breached their employment agreements by using and disclosing confidential company information. The Defendant, Boston Scientific Neuromodulation Corp. (“Boston Scientific”) is a medical device manufacturer. While in Boston Scientific’s employ, the whistleblowers signed employment agreements which, among … Continue Reading

Efforts to Stop Health Insurance Fraud Through Use of Contractors Under Fire

In recent reports, from June 25, 2014 and August 13, 2014, the Government Accountability Office (GAO) highlights the mixed results achieved by the federal government’s increased efforts to crack down on health insurance fraud through the use of contractors. The government has spent upwards of $600 million a year to uncover and punish health care fraud and overpayments, but  some … Continue Reading

New OIG Special Fraud Alert Aimed at Laboratory Payments to Referring Physicians

On June 25, 2014, the U.S. Department of Health and Human Services Office of Inspector General (OIG) issued a Special Fraud Alert entitled “Laboratory Payments to Referring Physicians.” While the Alert breaks no new ground (see, e.g., its 1994 Special Fraud Alert), it demonstrates the OIG’s continuing concerns about clinical laboratories’ offering inducements to referring physicians.

The … Continue Reading

CMS Releases Unprecedented Amount of Medicare Billing Information, Increasing Risk Related to Fraud Lawsuits

On April 9, 2014, the Center for Medicare and Medicaid Services (“CMS”), a branch of the Department of Health and Human Services (“HHS”), released data showing utilization, payments, and submitted charges for services and procedures that were provided by physicians and other healthcare professionals to Medicare beneficiaries.  This unprecedented release of Medicare billing information seeks to improve transparency in the … Continue Reading

CMS Now Requiring Qualified Health Plans to Accept Premium Payments from Certain Third Parties

As previously reported on November 13, 2013 and February 20, 2014, the Centers for Medicare and Medicaid Services (“CMS”) has attempted to provide guidance as to when it is appropriate for issuers of “qualified health plans” (“QHPs”) to accept third parties premium payments on behalf of individuals.

On March 19, 2014, CMS reinforced its February 7, 2014 guidance by … Continue Reading

Halifax Health and Government Settle False Claims Act Claims for $85 Million, But Case is Not Over

On March 10, 2014, Halifax Hospital Medical Center and Halifax Staffing, Inc. (collectively, “Halifax”) entered into a settlement agreement and a corporate integrity agreement (“CIA”) to resolve claims brought under the False Claims Act (“FCA”), alleging Halifax entered into improper incentive compensation arrangements with certain physicians in exchange for Medicare referrals. Halifax agreed to, among other things, pay $85 million … Continue Reading

HHS Allows Third-Party Premium Payments by Tribes and Non-Profits

We previously reported that the U.S. Department of Health and Human Services (“HHS”) has discouraged hospitals and other third parties from paying patients’ premiums or cost-sharing. HHS stated in its November 4, 2013 FAQ that it “has significant concerns with this practice because it could skew the insurance risk pool and create an unlevel field in the Marketplaces.” In other … Continue Reading

Department of Health and Human Services Office of Inspector General’s FY 2014 Work Plan Identifies Security of EHR Technology as New Focus

On January 31, 2014, the U.S. Department of Health and Human Services (“HHS”) Office of Inspector General (“OIG”) released its annual work plan.  Not surprisingly, issues relating to Electronic Health Records (“EHRs”) continue to receive significant attention.

Pursuant to the American Recovery and Reinvestment Act of 2009, OIG received funding to evaluate whether funds received by HHS agencies and grantees … Continue Reading

HHS Guidance Clouds Earlier Statement, Discourages Providers From Purchasing Insurance for Patients

There has been much speculation in the health care community that it may be financially beneficial, under certain circumstances, for hospitals and other large providers to purchase health care coverage for their indigent patients.  U.S. Department of Health and Human Services Secretary Kathleen Sebelius recently stated that Qualified Health Plans, which are sold on the federal health care Marketplace, are … Continue Reading

PODs Continue to Attract Scrutiny from OIG and Congress

In the wake of a recent U.S. Department of Health and Human Services Office of Inspector General (“OIG”) investigation, physicians with ownership interests in medical device distributorships and hospitals should prepare for an uptick in the scrutiny of physician-owned distributorships (“PODs”). The OIG investigation generated a report, Physician-Owned Distributors of Spinal Devices: Overview of Prevalence and Utilization and follows the … Continue Reading

Failure to Comply with Physician Supervision Requirements Can Be Costly

The Department of Justice recently announced two large settlement agreements with provider organizations and individual physicians based on failure to provide proper physician  supervision for diagnostic imaging and radiation therapy procedures.

In the first settlement, announced on August 27, 2013, Imagimed, LLC, a New York based diagnostic testing company, and certain individuals formerly associated with the company agreed to pay … Continue Reading

Inpatient or Outpatient Surgery: False Claims or Legitimate Difference in Medical Judgment?

It can be financially costly for hospitals to submit claims for inpatient surgical procedures which can be performed safely and effectively as an outpatient procedure.

The Department of Justice recently announced a settlement in which 55 hospitals in 21 states agreed to pay a total of $34 million for performing kyphoplasty procedures on an inpatient basis rather than as an … Continue Reading

Tuomey Standing Firm in Face of “Stark” Penalties

The next round in United States ex. rel. Drakeford v. Tuomey Healthcare System, Inc., is underway and Tuomey Healthcare keeps fighting.  As previously reported, on May 8, 2013, a federal jury found that Tuomey Healthcare System, a non-profit system in South Carolina, violated the Stark law and the False Claims Act in connection with its compensation structure for … Continue Reading

Second Time Around Tuomey Healthcare System is Found to Have Violated Stark Law and False Claims Act; Faces Penalties of up to $357 Million

In the ongoing saga of U.S. ex. rel. Drakeford v. Tuomey Healthcare System, Inc., on May 8, 2013, a South Carolina jury found that Tuomey violated the Stark Law and the False Claims Act.  The jury determined that Tuomey submitted over 21,000 improper claims, totaling $39 million. When penalties and treble damages of up to $11,000 per claim are … Continue Reading

Staying Out of the Principal’s Office: The OIG Revamps the Provider Self Disclosure Protocol

Introduction:

I have a vivid memory of sitting next to my father in an elementary school principal’s office.  The facts were: (1) three “student of the week” ice cream vouchers had gone missing from my teacher’s desk; (2) I was a somewhat portly child; and (3) I had tried, albeit unsuccessfully, to cash in one of those illicit vouchers at … Continue Reading

CMS Proposes Changes to Electronic Medical Records Rules

I. Overview:

The Centers for Medicare and Medicaid Services (CMS) and the Department of Health and Human Services’ (OIG) have issued a pair of proposed rules (see CMS rule, OIG rule) that seek to revise the current Electronic Health Records exceptions to the Physician Self-Referral (Stark) and Anti-Kickback laws.

The proposed rules would amend the current … Continue Reading

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