Healthcare reform in the United States

The United States has intervened in a lawsuit and filed a complaint against H. Ted Cain, Julie Cain, Corporate Management Inc, and Stone County Hospital Inc for submitting false claims to the Medicare program by knowingly charging excessive and ineligible expenses from 2002 to the present.  

The government’s complaint alleges that the Cains as well as the hospital and the management company abused the special Medicare rules for rural hospitals.  In particular, the government contends that they claimed to be serving the hospital in various management and directorship positions but in fact did little of the work for which the hospital paid them and any work they did duplicated work performed by the hospital and the management company staff, which were also paid by the hospital.  The government also contends that Ted Cain improperly claimed the expenses for his personal luxury automobiles on the hospital’s cost reports and his management company wrongfully charged to the hospital work that he did at his other businesses.

A settlement has been reached in a whistleblower class action lawsuit brought against The University of Medicine and Dentistry of New Jersey (UMDNJ) who is accused of defrauding Medicaid by submitting duplicate claims for payment.

The whistleblower will receive a $801,000 share of the total federal recovery.

The whistleblwoer case, filed in July 2004, alleged that From 1993 to 2004, UMDNJ’s University Hospital submitted claims to Medicaid for outpatient physician services that were also being billed by doctors working in the hospital’s outpatient centers. By submitting duplicate claims for payment, University Hospital effectively doubled billed the government’s Medicaid program.

A settlement has been reached in a whistleblower class action lawsuit brought against GE Healthcare Inc regarding a company it acquired in 2004, Amersham Health Inc.  Amersham is accused of causing Medicare to make overpayments by providing false or misleading information.

The whistleblower will receive $5.1 million from the government’s recovery.

The whistleblower lawsuit, filed in 2006, alleged that Amersham Health provided false or misleading information to Medicare regarding the number of doses available from vials, causing Medicare to pay for Myoview at artificially inflated rates. Myoview is distributed in multi-dose vials of powder. In a process known as reconstitution, nuclear pharmacies mix the powder with a radioactive agent to prepare individual doses that are injected into patients as part of the cardiac imaging procedures. Certain Medicare payment rates for Myoview were based, in part, on the number of doses available from vials of Myoview.

A settlement has been reached in a whistleblower class action lawsuit brought against Jackson-Madison County General Hospital who is accused of overbilling Medicare and Medicaid for certain cardiac procedures.

The whistleblower's portion of the settlement was not disclosed.

The lawsuit, filed in 2007, alleged that Jackson-Madison County General Hospital placed cardiac stents in patients when the procedure was not required, together with other cardiac procedures that were deemed not medically necessary. The hospital, according to allegations stemming from an investigation and a whistleblower healthcare fraud lawsuit, then billed Medicare and Medicaid.

A settlement has been reached to resolve False Claims Act Allegations against Dr. Walter Janke, his wife, Lalita Janke, and Vero Beach, Fla.-based Medical Resources L.L.C. (MR).  They are accused of submitting false diagnosis codes to Medicare.

The Jankes were the owners of America’s Health Choice Medical Plans Inc. (AHC), a Medicare Advantage Organization (MAO), approved by the federal health care program to provide health care to enrolled Medicare beneficiaries. The Jankes also owned MR, AHC’s primary care provider. AHC and MR are no longer doing business.

The United States allged that the Jankes and MR violated the False Claims Act by causing AHC to falsely increase the severity of beneficiary diagnoses to obtain higher Medicare payments. Under the Medicare Advantage Program, MAO's are paid more to provide services for members with serious and/or chronic medical conditions then they are for relatively healthy members.

In addition to suing the Jankes and MR, the United States successfully petitioned the court to freeze approximately $20 million of the Janke's assets believed to be the proceeds of their unlawful scheme. A portion of the Janke’s frozen assets, along with monies resulting from the dissolution of AHC now held in receivership by the Florida Department of Financial Services, will be used to pay the settlement.

A settlement has been reached in a whistleblower class action lawsuit brought against El Centro Regional Medical Center who is accused of defrauding Medicare.

The whistleblower will receive $375,000.

The original lawsuit was filed in May 2006. The United States alleged that the 165-bed acute care hospital fraudulently inflated its charges to Medicare patients to obtain larger reimbursements from the federal health care program. The settlement covers claims submitted by the hospital for short inpatient admissions, usually of one day or less, when the services should have been billed on an outpatient “observation” basis or as emergency room visits.

A settlement has been reached in a whistleblower class action lawsuit brought against Metropolitan Ambulance & First Aid Corp, Metro North Ambulance Corp, Big Apple Ambulance Service Inc, including their president, Steve Zakheim. They are accused of falsifying records to appeal a Medicare program refund demand.

The whistleblower will receive $618,450.

The original whistleblower case was filed in 2000.  The United States alleged that the companies and Zakheim used, or caused the use of, falsified records to appeal a Medicare program refund demand. Medicare had demanded the companies return millions of dollars they had been paid for medically unnecessary ambulance trips. Under Medicare rules, the companies could bill for these expensive non-emergency transports only if the patient could not be transported by any other means, such as by car or by wheelchair van. Medicare audited the companies’ past billings and concluded that the companies had charged Medicare tens of millions of dollars for ambulance trips that did not meet this standard. Medicare demanded a refund and afforded the companies an extensive informal and formal appeals process to prove that their billings were proper.

The government contended that, rather than contesting the refund demand fairly, the companies resorted to fraud when they could not otherwise prove an ambulance was medically needed. According to the suit, in their ensuing appeals, the companies used, and Zakheim caused the use of, hundreds of letters attesting to the need for an ambulance that were forged or otherwise purported to come from some neutral, disinterested health care provider when they in fact did not.

A settlement has been reached in a whistleblower class action lawsuit brought against Robert Wood Johnson University Hospital Hamilton fraudulently inflating its charges to Medicare. 

Whistleblowers that filed two lawsuits that these allegations are based upon will receive $1,111,250 of the total recovery.

The first of the lawsuits was filed in November 2002. The United States alleged that the hospital inflated its charges to obtain supplemental outlier payments for cases that were not extraordinarily costly and for which outlier payments should not have been paid. The United States intervened in both lawsuits in January 2008. 

In addition to its standard payment system, Medicare provides supplemental reimbursement, called "outlier payments," to hospitals and other health care providers in cases where the cost of care is unusually high. Congress enacted the supplemental outlier payments system to ensure that hospitals have the incentive to treat inpatients whose care requires unusually high costs.

A settlement has been reached to Resolve False Claims Act allegations against Mercy Hospital Inc (d/b/a Mercy Medical Center) of Springfield, MA, who is accused of failing to adhere to Medicare guidelines.

In June 2007, Mercy disclosed to the Department of Health and Human Services Office of Inspector General that it could not demonstrate that it had provided the required level of therapy.

The settlement resulted from the company’s disclosure.  The allegations were that Mercy Medical Center, between 2005 and 2006, failed to provide, or failed to document that it provided, the minimum number of hours of rehabilitation therapy required under Medicare guidelines.

Under Medicare, inpatient rehabilitation hospitals must provide a minimum amount of rehabilitative therapy to their patients.

A settlement has been reached in a whistleblower class action lawsuit brought against two New Jersey hospitals,Our Lady of Lourdes Medical Center (OLL) in Camden, N.J., and Lourdes Medical Center of Burlington County (LMC) in Willingboro, N.J. They are accused of fraudulently inflating charges to Medicare.

The whistleblower will receive $356,000, plus interest.

Originally filed in 2005, The United States alleged that LMC fraudulently inflated its charges to Medicare patients to obtain enhanced reimbursement from Medicare. In addition to its standard payment system, Medicare provides supplemental reimbursement, called "outlier payments," to hospitals and other health care providers in cases where the cost of care is unusually high. Congress enacted the supplemental outlier payments system to give hospitals the incentive to treat inpatients whose care requires unusually high costs. The lawsuit alleged that the hospital inflated its charges to obtain supplemental outlier payments for cases that were not extraordinarily costly and for which outlier payments should not have been paid.

The United States conducted a separate investigation of OLL. The government alleged, as a result of that investigation, that the hospital also wrongfully obtained excessive outlier payments.