Medicaid or Medicare Fraud

A settlement has been reached to resolve criminal and civil liability arising from GlaxoSmithKline LLC (GSK)’s unlawful promotion of certain prescription drugs, its failure to report certain safety data, and its civil liability for alleged false price reporting practices.

GSK agreed to plead guilty to a three-count criminal information, including two counts of introducing misbranded drugs, Paxil and Wellbutrin, into interstate commerce and one count of failing to report safety data about the drug Avandia to the Food and Drug Administration (FDA). Under the terms of the plea agreement, GSK will pay a total of $1 billion, including a criminal fine of $956,814,400 and forfeiture in the amount of $43,185,600. The criminal plea agreement also includes certain non-monetary compliance commitments and certifications by GSK’s U.S. president and board of directors. GSK’s guilty plea and sentence is not final until accepted by the U.S. District Court.

As part of this global resolution, GSK has agreed to resolve its civil liability for $2 billion to resolve the following alleged conduct: (1) promoting the drugs Paxil, Wellbutrin, Advair, Lamictal and Zofran for off-label, non-covered uses and paying kickbacks to physicians to prescribe those drugs as well as the drugs Imitrex, Lotronex, Flovent and Valtrex; (2) making false and misleading statements concerning the safety of Avandia; and (3) reporting false best prices and underpaying rebates owed under the Medicaid Drug Rebate Program.

A settlement has been reached in a whistleblower class action lawsuit brought against DaVita Healthcare Partners Inc who is accused of knowingly creating unnecessary waste in administering the drugs Zemplar and Venofer to dialysis patients, and then billing the federal government for such avoidable waste.

Filed in October of 2007, the whistleblowers’ complaint alleged that, to create unnecessary Zemplar waste, DaVita required its employees to provide Zemplar to dialysis patients pursuant to mandatory and wasteful “dosing grids.”  Zemplar, a Vitamin D supplement usually administered at every dialysis session, is packaged in single-use vial sizes of 2 mcg, 5 mcg, and 10 mcg. Davita allegedly created unnecessary waste by requiring its employees to provide Zemplar to dialysis patients pursuant to mandatory “dosing grids,” which were designed to maximize the amount of Zemplar administered to patients.  DaVita then allegedly billed the government not only for the amount of Zemplar administered to patients, but also for the amount “wasted.”

With regard to Venofer, an iron supplement packaged only in a single-use vial size of 100 mg during the relevant time period, DaVita allegedly enacted protocols that required nurses to administer this drug in small amounts, and at frequent intervals, to maximize wastage. For instance, in certain instances, DaVita’s protocol called for a patient to receive 25 mg of Venofer per week, which resulted in 300 mg of waste per month that was billed to the Government.  In contrast, if the order had been filled by giving the patient the entirety of a single 100 mg vial, once per month, no waste would have resulted.

A settlement has been reached in a whistleblower class action lawsuit brought against Amgen Inc who is accused of paying kickbacks to long-term care pharmacy providers.  

Filed in June 2011, the whistleblower lawsuit claims that Amgen Inc paid kickbacks to Omnicare in return for implementing “therapeutic interchange” programs that were designed to switch Medicaid beneficiaries from a competitor drug to Amgen’s product Aranesp. The complaint further alleged that the kickbacks took the form of performance-based rebates on Aranesp. As part of that program, the Government alleged that Amgen distributed materials designed to recommend Aranesp’s use in patients who did not have “anemia associated with chronic renal failure,” as specified in the approved labeling for Aranesp.

A settlement has been reached in a whistleblower class action lawsuit brought against Caremark LLC who is accused of knowingly failing to reimburse Medicaid for prescription drug costs paid on behalf of Medicaid beneficiaries, who also were eligible for drug benefits under Caremark-administered private health plans. Caremark is operated by CVS Caremark Corp.

The federal government will receive approximately $2.31 million and five states – Arkansas, California, Delaware, Louisiana and Massachusetts – will share $1.94 million under the settlement agreement. The whistleblower will receive approximately $505,680 from the federal government’s share of the settlement.

Filed in 2012, the government's complaint alleged that Caremark used a computer claims processing platform called “Quantum Leap” to cancel claims for reimbursement submitted by Medicaid for dual eligibles.  The complaint further claimed that Caremark’s actions caused Medicaid to incur prescription drug costs for dual eligibles that should have been paid for by the Caremark-administered private health plans rather than Medicaid.

A settlement has been reached in a whistleblower class action lawsuit brought against Recovery Home Care Inc, Recovery Home Care Services Inc. (collectively Recovery Home Care) and National Home Care Holdings LLC who are accused of improperly paying doctors for referrals of home health care services provided to Medicare patients.

The whistleblower will receive $198,000 of the recovered funds. 

The governments lawsuit, filed in 2012, alleged that from 2009 through 2012, Recovery Home Care paid dozens of physicians thousands of dollars per month to perform patient chart reviews.  Additionally, the complaint claims that the physicians were over-compensated for any actual work they performed and, in reality, payments to the physicians were used to induce them to refer their patients to Recovery Home Care, in violation of the Anti-Kickback Statute and the Stark Law.

A settlement has been reached in a whistleblower class action lawsuit brought against Community Health Systems Professional Services Corporation (CHSPSC) and three affiliated New Mexico hospitals (collectively Community Health Systems-CHS) who are accused of making illegal donations to county governments which were used to fund the state share of Medicaid payments to the hospitals.

The whistleblower will receive a $18,671,561 share of the government’s $75 settlement amount.

Filed in March 2005, the whistleblower case alleged that from August 1, 2000, through December 31, 2010, CHS knowingly caused the state of New Mexico to present false claims to the United States for payments made to CHS under New Mexico's Sole Community Provider program by making improper donations to Chaves, Luna and San Miguel counties, which were then used by the counties, and subsequently the state, to obtain federal matching payments.  The government alleged that CHS concealed the true nature of these donations to avoid detection by federal and state authorities, and as a result of its scheme, received SCP payments which were funded by the United States in the amount of three times CHS’ “donations.”

A settlement has been reached in a whistleblower class action lawsuit brought against Adventist Health System Sunbelt Healthcare Corporation who is accused of providing radiation oncology services to Medicare and TRICARE beneficiaries that were not directly supervised by radiation oncologists or similarly qualified persons.

The whistleblower will receive a $1,082,500 share of the $5,412,502 settlement.

Filed January 2013, the lawsuit specifically alleged that from January 1, 2010, through December 31, 2013, Adventist violated the supervision requirement for radiation oncology services provided to federal health care program beneficiaries at several Florida locations, including in Altamonte Springs, Daytona Beach, Deland, Kissimmee, Orange City, Orlando, Palm Coast and Winter Park.  These services included radiation simulation, dosimetry, radiation treatment delivery and devices, and intensity-modulated radiation therapy.

A settlement has been reached in a whistleblower class action lawsuit brought against Omnicare Inc who is accused of engaging in a kickback scheme in violation of the False Claims Act.

The settlement revolves both the civil accusations and criminal charges.  However, the whistleblower in this case will receive a portion of the civil share amount totallying $397,925.

Filed in June 2011, the whistleblower lawsuit claims that Omnicare solicited and received kickbacks from the drug manufacturer Amgen Inc in return for implementing “therapeutic interchange” programs that were designed to switch Medicaid beneficiaries from a competitor drug to Amgen’s product Aranesp.

A settlement has been reached in a whistleblower class action lawsuit brought against Halifax Hospital Medical Center and Halifax Staffing Inc (aka Halifax Health) who are accused of submitting claims to the Medicare program that violated the Physician Self-Referral Law, commonly known as the Stark Law.

The whistleblower will receive a $20.8 million share of the $85 million settlement.

Filed in June 2009, the lawsuit alleges that Halifax knowingly violated the Stark Law by executing contracts with six medical oncologists that provided an incentive bonus that improperly included the value of prescription drugs and tests that the oncologists ordered and Halifax billed to Medicare.  The government also alleged that Halifax knowingly violated the Stark Law by paying three neurosurgeons more than the fair market value of their work.

A settlement has been reached to resolve allegations brought about by the government against Teva Pharmaceuticals Industries Limited and IVAX LLC, a Teva subsidiary, who are accused of making payments to induce prescriptions of an anti-psychotic drug for Medicare and Medicaid beneficiaries.

Under the terms of the settlement, Teva must pay the federal government close to $15.5 million and the state of Illinois more than $12.1 million.

The settlement resolves allegations that Teva and IVAX made payments to an Illinois physician, Dr. Michael J. Reinstein, to induce the prescription of generic clozapine, an anti-psychotic medication.  The United States alleged that the payment scheme involving Reinstein began in August 2003, when Reinstein agreed to switch his patients to generic clozapine if IVAX, which was subsequently acquired by Teva Pharmaceuticals’ parent corporation, agreed to pay Reinstein $50,000 under a one-year “consulting agreement” and to provide other benefits to Reinstein , in violation of the federal Medicare and Medicaid Anti-Kickback Statute. In addition to direct payments to Reinstein, IVAX allegedly also provided all-expenses paid trips to Miami for Reinstein, his wife and several of his employees.  Reinstein quickly became the largest prescriber of generic clozapine in the country, and prescribed the drug for many elderly patients.  Allegedly, the payments and other forms of remuneration from IVAX and later Teva Pharmaceuticals continued for many years, and resulted in the submission of thousands of false claims to the Medicare Part D and Illinois Medicaid programs.