Medicaid or Medicare Fraud

A settlement has been reached in a whistleblower class action lawsuit brought against CareSource, CareSource Management Group Co and CareSource USA Holding Co. They are accused of causing Medicaid to make payments for assessments and case managements they failed to provide to children and adults.

The whistleblowers will receive a $3.1 million share of the government's recovery.

Originally filed in November 2006, the United States alleged that between January 2001 and December 2006, the CareSource entities knowingly failed to provide required screening, assessment and case management for adults, and children with special health care needs. As a result, it was alleged that CareSource received millions of dollars in Medicaid funds to which it was not entitled. The CareSource entities subsequently submitted false data to the state of Ohio so that it appeared they were providing these required services to improperly retain incentives received from Ohio Medicaid and to avoid penalties.

A settlement has been reached to resolve False Claims Act Allegations against BlueCross BlueShield of Illinois who is accused of  wrongly terminating insurance coverage and denying patient claims, among other claims.

Under the agreement, BlueCross BlueShield of Illinois will pay $14.25 million to the state of Illinois and $9.5 million to the United States. The company will also pay $1.25 million to Illinois for allegations under the state consumer fraud statute.

In detail, the United States contends that BlueCross BlueShield of Illinois wrongly terminated insurance coverage for private duty skilled nursing care for medically fragile, technologically dependent children, in order to shift the costs of such care to the Medicaid program. Medicaid funds a special program designed to provide home care for children at risk of institutionalization.

As a result, children whose specialized care should have been covered by BlueCross BlueShield of Illinois under the terms of existing insurance policies, were shifted to the government-funded Home and Community Based Services Medicaid program, operated by the Illinois Division of Specialized Care for Children under an agreement with the Illinois Department of Healthcare and Family Services. As a result, Medicaid spent millions of dollars providing care that should have been paid for by private insurance.

The settlement resolves claims that BlueCross BlueShield of Illinois denied patient claims based on internal, undisclosed guidelines that were more restrictive than the language provided to beneficiaries in plan policy materials. Additionally, the government alleged that BlueCross BlueShield of Illinois improperly told policy holders that children were not covered for private duty nursing during the claims review process sought after initial denials.

The whistleblowers will receive a $80,000 share of the government's recovery.

This lawsuit was originally filed in May 2008 and stemmed from a 2005 filing of a lawsuit against Kyphon Inc.  The United States' complaint alleged that Rex Healthcare routinely submitted claims to Medicare for a variety of minimally-invasive procedures during the period 2004 through 2007, which the hospital classified as inpatient admissions in order to increase its reimbursement from Medicare, despite the absence of medical necessity justifying the more expensive inpatient admissions. The government also made claims related to a variety of other minimally-invasive procedures that the hospital classified as inpatient admissions in order to increase its reimbursement when less costly outpatient visits would have been appropriate.

A settlement has been reached in a whistleblower class action lawsuit brought against CVS Pharmacy Inc  who is accused of submitting inflated prescription claims to the government.

Under the terms of the agreement with the United States and the 10 states, CVS will pay the United States $7,993,615.55 and the states $9,506,384.45 plus interest. The whistleblower will receive a total of $2,595,460: $1,278,978 of the United States’ recovery and $1,316,482 of the state proceeds from California, Florida, Indiana, Massachusetts, Michigan, New Hampshire, Nevada and Rhode Island. Alabama and Minnesota do not have state False Claims Act statutes.

Originally filed in September 2008, the United States alleged CVS submitted inflated prescription claims to the government by billing the Medicaid programs in Alabama, California, Florida, Indiana, Massachusetts, Michigan, Minnesota, New Hampshire, Nevada and Rhode Island for more than what CVS was owed for prescription drugs dispensed to Medicaid beneficiaries who were also eligible for benefits under a primary third party insurance plan (excluding Medicare as the primary payor). The United States also alleged that rather than billing the government for what the insured would have been obligated to pay had the claims been submitted solely to the third party insurer (typically the co-pay), CVS billed and was paid a higher amount by Medicaid.

A settlement was reached to resolve False Claims Act allegations against Serono Laboratories Inc., EMD Serono Inc., Merck Serono S.A, and Ares Trading S.A. They are accused of paying health care providers to promote or prescribe Rebif, a recombinant interferon injectable that is used to treat relapsing forms of multiple sclerosis. 

Under the terms of the agreemen, the proceeds from the settlement will be split between the federal government and various states, with the United States receiving $34.6 million to resolve the federal claims and the states receiving $9.7 million to settle their respective claims under Medicaid.

Serono is alleged to have made payments to providers for hundreds of speaker training meetings and programs, as well as payments for attending consultant, marketing and advisory board meetings, all at upscale resorts and other locations. Serono’s actions allegedly resulted in the submission of false claims to federal health care programs including Medicare and Medicaid for the payment of Rebif, i.e., claims that were tainted by kickbacks.

A settlement has been reached in a whistleblower class action lawsuit brought against Midtown Imaging LLC, a radiology clinic, and its former owners Midtown Imaging P.A. and PBC Medical Imaging. They are accused of submitting false claims to Medicare during the period 2000 through 2008.

The whistleblowers will share in $600,000 of the government's recovery.

Originally filed in November 2009, the United States alleged that the West Palm Beach clinic is alleged to have submitted false claims to Medicare during the period 2000 through 2008 by entering into certain leasing and professional services agreements with referring physicians and physician groups that violated the Anti-Kickback Statute and Stark Law.

A settlement has been reached to resolve False Claims Act allegations against Rakesh Nathu, a Las Vegas physician, who is accused of submitting false claims to federal health care programs for various radiation oncology services.

The government alleges that Nathu submitted improper claims to Medicare, TRICARE and the Federal Employees Health Benefits Plan from 2007 through 2009 in which he double billed for several procedures affiliated with radiation treatment plans, billed for certain high reimbursement radiation oncology services when a different, less expensive service should have been billed and billed for medically unnecessary radiation oncology services. One of these treatments included intensity modulated radiation therapy. Intensity modulated radiation therapy is a sophisticated radiation treatment indicated for specific types of cancer where extreme precision is required to spare surrounding organs or healthy tissue.

A settlement has been reached in a whistleblower class action lawsuit brought against Janzen, Johnston & Rockwell Emergency Medicine Management Services Inc. (JJ&R), who is accused of submitting false claims to Medicare and Louisiana’s Medicaid program.

The whistleblower will receive $774,450 of the government's recovery.

Originally filed in July 2003, the United States alleged that JJ&R inflated claims that it had coded on behalf of emergency room physicians in Louisiana and California. From approximately 2000 through 2007, JJ&R utilized a coding formula that had a tendency to generate claims for a marginally higher level of evaluation and management service than the physicians had actually provided. In addition, JJ&R routinely added charges to the evaluation and management claim for minor services, such as pulse oximetry, that had been provided by hospital nursing staff or other physicians. Additionally, during this time period, the government alleged that JJ&R often failed to comply with Medicare’s coding rules governing the submission of claims for teaching physicians, resulting in the submission of claims that were not properly payable. While these coding practices had a relatively small impact on the reimbursement of any particular claim, over time they generated significant overpayments from Medicare and Medicaid.

A settlement has been reached in a whistleblower class action lawsuit brought against TriWest Healthcare Alliance Corporation who is accused of submitting claims to TRICARE at higher rates billed by the providers.

The four whistleblowers that filed this case will receive $1.7 million as their share of the government’s recovery.

Originally filed August 2008, the United States alleged that between 2004 and 2010, TriWest failed to give TRICARE the benefit of negotiated discounts with service providers under letters of agreement (LOAs).  Notwithstanding contractually binding LOAs with health care providers, TriWest submitted claims to TRICARE at higher rates billed by the providers, failing to pass on to TRICARE the savings negotiated through the LOAs.

A settlement has been reached in a whistleblower class action lawsuit brought against LHC Group Inc who is accused of falsifying home healthcare billings to the Medicare, TRICARE and Federal Employees Health Benefits programs.

The whistleblower will receive over $12 million of the government’s recovery.

Originally filed in July 2007, the United States alleged that, between 2006 and 2008, LHC improperly billed for services that were not medically necessary and for services rendered to patients who were not homebound.