For years, CMS has had the authority to refuse to enroll new Medicare providers if they or their owners have an unpaid Medicare overpayment, but CMS was not exercising this authority. Now, it appears that CMS is going to start. In January, CMS published Transmittal 1998 announcing that it intends to begin denying provider enrollment applications, or change-of-ownership applications, where … Continue Reading
Defendants have faced an ever increasing number of qui tam actions, yet the government has historically declined to seek dismissal of those actions where it declined to intervene. On January 10, 2018, the Director of the DOJ Civil Division Commercial Litigation Branch’s Fraud Section issued a memorandum to all DOJ attorneys, including AUSAs, advising them that when declining to intervene … Continue Reading
The United States District Court for the Middle District of Florida vacated a large jury verdict in a False Claims Act case against the owners and operators of nursing homes because the evidence did not satisfy the materiality standards articulated in the U.S Supreme Court’s 2016 opinion in Universal Health Services v. Escobar.
The court’s thorough and well-written opinion … Continue Reading
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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