KENTUCKY HOSPITAL SETTLES ALLEGATIONS OF PERFORMING MEDICALLY UNNECESSARY CARDIAC PROCEDURES

FROM:  JUSTICE DEPARTMENT 
Wednesday, January 29, 2014
Kentucky Hospital Agrees to Pay Government $16.5 Million to Settle Allegations of Unnecessary Cardiac Procedures

Saint Joseph Health System Inc. has agreed to pay $16.5 million to resolve allegations that Saint Joseph Hospital violated the False Claims Act by submitting false claims to the Medicare and Kentucky Medicaid programs for a variety of medically unnecessary cardiac procedures, the Justice Department announced today.  Saint Joseph Health System operates numerous hospitals statewide, including Saint Joseph Hospital, which is based in London, Ky.

“Hospitals that place their financial interests above the well-being of their patients will be held accountable,” said Assistant Attorney General for the Justice Department’s Civil Division Stuart F. Delery. “ The Department of Justice will not tolerate those who abuse federal health care programs and put the beneficiaries of these programs at risk.”

The government alleged that doctors working at Saint Joseph Hospital performed numerous invasive cardiac procedures, including coronary stents, pacemakers, coronary artery bypass graft surgeries and diagnostic catheterizations, on Medicare and Medicaid patients who did not need them, and that the hospital was aware of these unnecessary procedures.  These doctors were affiliated with Cumberland Clinic which is a physician group that entered an exclusive arrangement with Saint Joseph Hospital in 2008 to provide cardiology services to the hospital’s patients.  Cumberland Clinic is owned by two London-based cardiologists, Satyabrata Chatterjee and Ashwini Anand.

The settlement also resolves allegations that Saint Joseph Hospital violated the federal Stark Law and Anti-Kickback Statute by entering into sham management agreements that financially benefitted Chatterjee and Anand as an inducement for Chatterjee and Anand to direct more Cumberland Clinic patients to the hospital.

Dr. Sandesh Patil, one of the Cumberland Clinic cardiologists working at the hospital, performed many of the medically unnecessary coronary stents.  Patil has since pleaded guilty to a federal health care fraud offense and has been sentenced to serve 30 months in prison.

“We all rely on health care providers to make treatment decisions based on clinical, not financial, considerations,” said U.S. Attorney for the Eastern District of Kentucky Kerry Harvey.  “The conduct alleged in this case violates that fundamental trust and squanders scarce public resources set aside for legitimate health care needs.  We will use every available tool to protect our federal health care programs and the patients who they serve.”

In connection with this settlement, Saint Joseph Hospital has agreed to enter into a Corporate Integrity Agreement with the Department of Health and Human Services Office of Inspector General (HHS-OIG), which obligates the hospital to undertake substantial internal compliance reforms and to commit to a third-party review of its claims to federal health care programs for the next five years.

"Cases such as this threaten both the health of patients and the financial integrity of the Medicare and Medicaid programs," said Special Agent in Charge at the U.S. Department of Health and Human Services Office of Inspector General in Atlanta Derrick L. Jackson.  "This settlement is another example of the OIG’s commitment to protecting our beneficiaries and to recovering any money that has been improperly paid as a result of medically unnecessary procedures."

In addition to the settlement with Saint Joseph Health System, the government  announced its intervention in a lawsuit alleging False Claims Act violations by Chatterjee and Anand, who referred patients for and performed the unnecessary procedures and tests, and their practice group, Cumberland Clinic, as well the practice groups each of them owned before forming Cumberland Clinic.    

The government actions announced today stem in large part from a whistleblower complaint filed by three Lexington, Ky., cardiologists pursuant to the qui tam provisions of the False Claims Act, which permit private persons to bring a lawsuit on behalf of the government and to share in the proceeds of the suit.  The Act also permits the government to intervene in the lawsuit and take over the allegations as it has done in this case.  Drs. Michael Jones, Paula Hollingsworth and Michael Rukavina will receive a total of $2.46 million of the $16.5 million settlement with Saint Joseph Hospital.

This settlement illustrates the government’s emphasis on combating health care fraud and marks another achievement for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced in May 2009 by Attorney General Eric Holder and Secretary of Health and Human Services Kathleen Sebelius.  The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation.  One of the most powerful tools in this effort is the False Claims Act.  Since January 2009, the Justice Department has recovered a total of more than $17.1 billion through False Claims Act cases, with more than $12.2 billion of that amount recovered in cases involving fraud against federal health care programs.

The investigation was conducted by the FBI, HHS-OIG, the Kentucky Office of Attorney General, Medicaid Fraud and Abuse Control Unit, the Commercial Litigation Branch of the Department of Justice Civil Division and the U.S. Attorney’s Office for the Eastern District of Kentucky.  The claims settled by this agreement are allegations only, and there has been no determination of liability.

The lawsuit is captioned United States ex rel. Jones, Hollingsworth and Rukavina v. Saint Joseph Health System et al., no. 11-cv-81-GFVT (E.D.Ky.)

DOCTOR INDICTED FOR ALLEGED ROLE IN $158 MILLION MEDICARE FRAUD

FROM:  U.S. JUSTICE DEPARTMENT 
Tuesday, December 17, 2013
Houston Doctor Indicted for Her Alleged Role in $158 Million Medicare Fraud Scheme

A Houston doctor has been arrested on charges related to her alleged participation in a $158 million Medicare fraud scheme involving false claims for mental health treatment.

Acting Assistant Attorney General Mythili Raman of the Justice Department’s Criminal Division, U.S. Attorney Kenneth Magidson of the Southern District of Texas, Special Agent in Charge Stephen L. Morris of the FBI’s Houston Field Office, Special Agent in Charge Mike Fields of the Dallas Regional Office of the Department of Health and Human Services Office of the Inspector General (HHS-OIG) and the Texas Attorney General’s Medicaid Fraud Control Unit (MFCU) made the announcement.

Sharon Iglehart, 56, of Houston, was charged in an indictment, filed in the Southern District of Texas and unsealed today, with one count of conspiracy to commit health care fraud and four counts of health care fraud.   If convicted, Iglehart faces a maximum penalty of 10 years in prison on each count.   Iglehart was arrested on Dec. 16, 2013, and made her initial appearance in federal court in Houston today.

According to the indictment, Iglehart allegedly participated in a scheme to defraud Medicare beginning in 2005 and continuing until May 2012.  The defendant allegedly caused the submission of false and fraudulent claims for partial hospitalization program (PHP) services to Medicare through a Houston hospital.  A PHP is a form of intensive outpatient treatment for severe mental illness.

The indictment alleges that the defendant and her co-conspirators submitted or caused to be submitted approximately $158 million in claims to Medicare for PHP services purportedly provided by the hospital, when in fact the PHP services were medically unnecessary or never provided.

In February 2012, Mohammad Khan, an assistant administrator at the hospital who managed many of the hospital’s PHPs, was indicted for his role in the scheme.   Khan pleaded guilty to one count of conspiracy to commit health care fraud, one count of conspiracy to pay illegal kickbacks, and five counts of paying illegal kickbacks.   Khan has not yet been sentenced.

In October 2012, Earnest Gibson III, the administrator of the hospital, along with Earnest Gibson IV, William Bullock III, Robert Ferguson, Regina Askew, Leslie Clark and Robert Crane, were indicted for their roles in the scheme.   Leslie Clark pleaded guilty to one count of conspiracy to pay and receive illegal kickbacks.   Clark has not yet been sentenced.

An indictment is merely an allegation, and the defendant is presumed innocent unless and until proven guilty beyond a reasonable doubt in a court of law.

The case was investigated by the FBI, HHS-OIG, MFCU, Internal Revenue Service’s Houston Field Office, the Chicago Field Office of the Railroad Retirement Board’s Office of Inspector General, and the Office of Personnel Management’s Office of Inspector General and was brought as part of the Medicare Fraud Strike Force, under the supervision of the Criminal Division’s Fraud Section and the U.S. Attorney’s Office for the Southern District of Texas.   The case is being prosecuted by Assistant Chief Laura M.K. Cordova of the Criminal Division’s Fraud Section.

Since its inception in March 2007, the Medicare Fraud Strike Force, now operating in nine cities across the country, has charged more than 1,700 defendants who have collectively billed the Medicare program for more than $5.5 billion.   In addition, the HHS Centers for Medicare and Medicaid Services, working in conjunction with the HHS-OIG, are taking steps to increase accountability and decrease the presence of fraudulent providers.

COMPANY TO PAY $14.5 MILLION TO SETTLE OVERBILLING ALLEGATIONS

FROM: U.S. DEPARTMENT OF JUSTICE
Wednesday, July 3, 2013

Tacoma, Wash., Medical Firm to Pay $14.5 Million to Settle Overbilling Allegations

Bills Claimed Higher Level of Service Than Was Documented

Sound Inpatient Physicians Inc. will pay $14.5 million to settle allegations that it overbilled Medicare and other federal health care programs, the Justice Department announced today. Sound Physicians is a Tacoma, Wash.-based provider of hospitalists and other physicians to hospitals and other medical facilities. It employs more than 700 hospitalists and post-acute physicians, who provide services at 70 hospitals and a growing network of post-acute facilities in 22 states.


"Physicians who participate in Medicare and other federal health care programs must document and bill for their services accurately and honestly," said Stuart F. Delery, Acting Assistant Attorney General for the Civil Division. "The Department of Justice is committed to ensuring that Medicare and other federal funds are expended appropriately."

Today’s settlement addresses allegations that, between 2004 and 2012, Sound Physicians knowingly submitted to federal health benefits programs inflated claims on behalf of its hospitalist employees for higher and more expensive levels of service than were documented by hospitalists in patient medical records. Hospitalists are physicians, typically trained in internal medicine, who provide care exclusively to hospital inpatients and have no office or outpatient practice.

"Fraudulently inflated billing of government health care programs puts those programs at risk, and impacts the system’s ability to care for the neediest in our communities," said Jenny A. Durkan, U.S. Attorney for the Western District of Washington. "During this time of tight government budgets, we will do all we can to make sure everyone plays by the rules and does not run up the taxpayers’ tab."

Allegations that Sound Physicians had improperly billed a variety of federal health care programs were brought to the government’s attention through a lawsuit filed by a former Sound Physicians employee, Craig Thomas, under the qui tam, or whistleblower, provisions of the False Claims Act. The act allows private citizens to bring civil actions on behalf of the government and share in any recovery. Thomas will receive $2.7 million of the $14.5 million settlement for exposing Sound Physicians’ inflated claims.

This civil settlement illustrates the government’s emphasis on combating health care fraud and marks another achievement for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced in May 2009 by Attorney General Eric Holder and Health and Human Services Secretary Kathleen Sebelius. The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation. One of the most powerful tools in this effort is the False Claims Act. Since January 2009, the Justice Department has recovered a total of more than $14.7 billion through False Claims Act cases, with more than $10.7 billion of that amount recovered in cases involving fraud against federal health care programs.

The Sound Physicians settlement was the result of a coordinated effort by the Department of Justice, Civil Division, Commercial Litigation Branch; the U.S. Attorney’s Office for the Western District of Washington; the Department of Health and Human Services Office of Inspector General; the Department of Defense, Office of Inspector General, Defense Criminal Investigative Service; the Office of Personnel Management Office of Inspector General; the Department of Veterans’ Affairs Office of Inspector General; and the TRICARE Management Activity Office of General Counsel.

REGIONAL MEDICAL CENTER AND HEART CENTER TO PAY $4.4 MILLION TO SETTLE FALSE CLAIMS ACT ALLEGATIONS

FROM: U.S. DEPARTMENT OF JUSTICE

EMH Regional Medical Center and North Ohio Heart Center to Pay U.S. $4.4 Million to Resolve False Claims Act Allegations

EMH Regional Medical Center (EMH) has agreed to pay the United States $3,863,857 and North Ohio Heart Center Inc. (NOHC) has agreed to pay the United States $541,870 to settle allegations that they submitted false claims to Medicare, the Justice Department announced today.

EMH is a non-profit community hospital system located in Lorain County, Ohio. During the relevant time period, NOHC was an independent physician group located in Lorain County that practiced at EMH. The settlement resolves allegations that between 2001 and 2006 EMH and NOHC performed unnecessary cardiac procedures on Medicare patients. Specifically, the United States alleged that EMH and NOHC performed angioplasty and stent placement procedures on patients who had heart disease but whose blood vessels were not sufficiently occluded to require the particular procedures at issue.

"Billing Medicare for cardiac procedures that are not necessary or appropriate contributes to the soaring costs of health care and puts patients at risk. The settlement demonstrates the Department of Justice’s efforts both to protect public funds and safeguard Medicare beneficiaries," said Stuart F. Delery, Principal Deputy Assistant Attorney General of the Justice Department’s Civil Division.

" Most doctors act responsibly," said Steven M. Dettelbach, U.S. Attorney for the Northern District of Ohio. " These few didn't. Patient health and taxpayer dollars have to come before greed."

This matter was initiated by the filing of a whistleblower complaint under the False Claims Act (FCA). Under the FCA, private citizens can bring suit for false claims on behalf of the United States and receive a share of the recovery obtained by the government. The whistleblower in this matter, Kenny Loughner, was the former manager of EMH’s catheterization and electrophysiology laboratory. As a result of the settlement, Mr. Loughner will receive $660,859 of the United States’ recovery.

This resolution is part of the government’s emphasis on combating health care fraud and another step for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced by Attorney General Eric Holder and Kathleen Sebelius, Secretary of the Department of Health and Human Services in May 2009. The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation. One of the most powerful tools in that effort is the False Claims Act, which the Justice Department has used to recover more than $10.1 billion since January 2009 in cases involving fraud against federal health care programs. The Justice Department’s total recoveries in False Claims Act cases since January 2009 are over $13.8 billion.

The investigation was jointly handled by the U.S. Attorney’s Office for the Northern District of Ohio, the Justice Department’s Civil Division, the Office of the Inspector General of the Department of Health and Human Services Cleveland Field Office and the FBI. The claims resolved by this settlement are allegations only, and there has been no determination of liability.

4 CHARGED IN DETROIT FOR ALLEGED $24.7 MILLION MEDICARE FRAUD SCHEME

Photo:  Detroit GM Building.  Credit:  Wikimedia.
FROM: U.S. DEPARTMENT OF JUSTICE
Thursday, September 20, 2012

Five Individuals Charged in Detroit for Alleged Roles in $24.7 Million Medicare Fraud Scheme

Four Additional Defendants Were Previously Charged for Their Roles in the Scheme

WASHINGTON – Five individuals were charged in court documents unsealed today in the Eastern District of Michigan for their participation in a Medicare fraud scheme involving purported home health and psychotherapy services, announced the Department of Justice, the FBI and the Department of Health and Human Services (HHS).

According to court documents, the scheme allegedly involved a total of more than $24.7 million in fraudulent claims submitted to Medicare for purported home health care and psychotherapy services that were medically unnecessary and/or never provided.

Court documents allege that the defendants are operators, employees and marketers associated with home health care and psychotherapy clinics operating in and around Detroit. Defendants charged in court documents unsealed today include: Mohammed Sadiq, 65, Troy, Mich.; Jamella Al-Jumail, 23, of Brownstown, Mich.; Firas Alky, 40, of Shelby Township, Mich.; Clarence Cooper, 53, of Detroit; and Beverly Cooper, 58, of Detroit.

Four defendants charged in the superseding indictment were previously charged and arrested in May 2012 for their roles in the scheme. Defendants previously charged include: Sachin Sharma, 36, of Shelby Township; Dana Sharma, 29, of Shelby Township; Abdul Malik Al-Jumail, aka Tony, 52, of Brownstown; Felicar Williams, 49, of Dearborn, Mich.

The superseding indictment charges all defendants with one count of conspiracy to commit health care fraud; Sachin Sharma with five counts of health care fraud; Sachin Sharma, Abdul Malik Al-Jumail, Williams, Sadiq, Alky and Clarence Cooper with one count of conspiracy to pay and receive health care kickbacks; and Jamella Al-Jumail with one count of destruction of records in a federal investigation. The superseding indictment also seeks forfeiture from all defendants.

According to the superseding indictment, from January 2007 through April 2012, the defendants operated a large network of purported home health care and psychotherapy companies in the Detroit area through which they conspired to defraud Medicare.

According to court documents, Sachin Sharma, Dana Sharma, Abdul Malik Al-Jumail, Williams, Jamella Al-Jumail, Sadiq, Alky and other alleged co-conspirators incorporated home health care, psychotherapy and other medical service companies to carry out the scheme, including Reliance Home Care, LLC; First Choice Home Health Care Services Inc.; Associates in Home Care Inc.; Haven Adult Day Care Center LLC; Swift Home Care LLC; ABC Home Care Inc.; Accessible Home Care Inc.; and Be Well Home Care LLC. The defendants, along with co-conspirators, allegedly submitted Medicare enrollment applications to permit these companies to bill Medicare. Sachin Sharma, Abdul Malik-Al-Jumail, Sadiq, Alky and others allegedly paid kickbacks and bribes to recruiters, including Williams and Clarence Cooper, to obtain Medicare beneficiaries’ information, which could be used to fraudulently bill Medicare for purported services provided by the companies they operated and controlled. The defendants then allegedly caused these companies to bill Medicare for home health and psychotherapy services, even though these services were not medically necessary and were often not provided.

According to the superseding indictment, the defendants caused Reliance, First Choice, Associates, Haven, Swift, ABC, Accessible and other home health, psychotherapy and medical services companies to submit approximately $24.7 million in claims to Medicare for services that were medically unnecessary and/or not provided. In addition, Jamella Al-Jumail is charged with destroying records relating to Accessible’s Medicare billings upon learning of the May 2012 arrest of Abdul Malik Al-Jumail, her co-conspirator and father.

Clarence and Beverly Cooper, Sadiq and Jamella Al-Jumail were arrested yesterday.

The case is being prosecuted by Fraud Section Assistant Chief Gejaa T. Gobena and Trial Attorney William G. Kanellis. The investigations were conducted jointly by the FBI and HHS-OIG, as part of the Medicare Fraud Strike Force, supervised by the U.S. Attorney's Office for the Eastern District of Michigan and the Criminal Division's Fraud Section.

CHARGES UNVEILED IN ALLEGED $97 MILLION MEDICARE FRAUD SCHEME

FROM: U.S. DEPARTMENT OF JUSTICE
Thursday, July 26, 2012

Owners and Employees of Houston Mental Health Company and Patient Recruiters Charged for Alleged Roles in $97 Million Medicare Fraud Scheme

A superseding indictment was unsealed today charging two owners of a Houston mental health care company, Spectrum Care P.A., some of its employees and the owners of Houston group care homes for their alleged participation in a $97 million Medicare fraud scheme, announced the Department of Justice, the Department of Health and Human Services (HHS) and the FBI.

Mansour Sanjar, 79, Cyrus Sajadi, 64, and Chandra Nunn, 34, were originally charged in December 2011, and are expected to make their initial appearances on the superseding indictment in the coming days. The indictment was originally retuned on July 24, 2012, and was unsealed today.

Adam Main, 31, Shokoufeh Hakimi, 65, Sharonda Holmes, 38, and Shawn Manney, 50, all from the Houston area, were arrested today and are expected to make their initial appearances in U.S. District Court for the Southern District of Texas in Houston either today or tomorrow.

The superseding indictment charges Sanjar, Sajadi, Main, Terry Wade Moore, 51, Hakimi and Nunn each with one count of conspiracy to commit health care fraud; Sanjar, Sajadi, Main and Moore are charged with various counts of health care fraud; Sanjar, Sajadi, Hakimi, Nunn, Holmes and Manney each are charged with one count of conspiracy to defraud the United States and to pay health care kickbacks; and Sanjar, Sajadi, Hakimi, Nunn, Holmes and Manney are charged with various counts of payment and receipt of healthcare kickbacks. The superseding indictment also seeks forfeiture.

According to the indictment, Sanjar and Sajadi orchestrated and executed a scheme to defraud Medicare beginning in 2006 and continuing until their arrest in December 2011. Sanjar and Sajadi owned Spectrum, which purportedly provided partial hospitalization program (PHP) services. A PHP is a form of intensive outpatient treatment for severe mental illness. The Medicare beneficiaries for whom Spectrum billed Medicare for PHP services did not qualify for or need PHP services. Sanjar, Sajadi, Main and Moore signed admission documents and progress notes certifying that patients qualified for PHP services, when in fact, the patients did not qualify for or need PHP services. Sanjar and Sajadi also billed Medicare for PHP services when the beneficiaries were actually watching movies, coloring and playing games – activities that are not covered by Medicare.

Sanjar, Sajadi and Hakimi paid kickbacks to Nunn, Holmes, Manney and other group care home operators and patient recruiters in exchange for delivering ineligible Medicare beneficiaries to Spectrum, according to the indictment. In some cases, the patients received a portion of those kickbacks. The indictment alleges that Spectrum billed Medicare for approximately $97 million in services that were not medically necessary and, in some cases, not provided.

Today’s charges were announced by Assistant Attorney General Lanny A. Breuer of the Justice Department’s Criminal Division; U.S. Attorney Kenneth Magidson of the Southern District of Texas; Special Agent in Charge Stephen L. Morris of the FBI’s Houston Field Office; Special Agent in Charge Mike Fields of the Dallas Regional Office of HHS’s Office of the Inspector General (HHS-OIG), the Texas Attorney General’s Medicaid Fraud Control Unit (MFCU); Joseph J. Del Favero, Special Agent in Charge of the Chicago Field Office of the Railroad Retirement Board, Office of Inspector General (RRB-OIG); and Scott Rezendes, Special Agent in Charge of Field Operations of the Office of Personnel Management, Office of Inspector General (OPM-OIG).

An indictment is merely a formal accusation. Defendants are presumed innocent unless and until proven guilty beyond a reasonable doubt in a court of law.

The case is being prosecuted by Trial Attorneys Laura M.K. Cordova and Allan J. Medina and Deputy Chief Sam S. Sheldon of the Criminal Division’s Fraud Section with assistance from Trial Attorneys Jennifer Ambuehl and Aixa Maldonado-Quinones of the Criminal Division’s Asset Forfeiture and Money Laundering Section. The case was investigated by the FBI, HHS-OIG, MFCU, RRB-OIG and OPM-OIG and was brought as part of the Medicare Fraud Strike Force, supervised by the Criminal Division’s Fraud Section and the U.S. Attorney’s Office for the Southern District of Texas.

Since its inception in March 2007, the Medicare Fraud Strike Force, now operating in nine cities across the country, has charged more than 1,330 defendants who have collectively billed the Medicare program for more than $4 billion. In addition, HHS’s Centers for Medicare and Medicaid Services, working in conjunction with HHS-OIG, is taking steps to increase accountability and decrease the presence of fraudulent providers.

　

PENNSYLVANIA RESIDENT INDICTED FOR ALLEGED AMBULANCE TRANSPORT FRAUD

Photo Credit:  Wikimedia.
FROM:  U.S. DEPARTMENT OF JUSTICE
Friday, June 29, 2012 Pennsylvania Man Charged with Fraud in Ambulance Scheme
A Churchville, Pa., man was arrested today on charges contained in a 23-count indictment for his alleged role in a scheme to defraud Medicare by billing for fraudulent ambulance services, announced Assistant Attorney General Lanny A. Breuer of the Justice Department’s Criminal Division and U.S. Attorney Zane D. Memeger.

An indictment unsealed today charges William V. Hlushmanuk, aka “Bill Le,” 35, of Churchville, Pa., with 21 counts of health care fraud, one count of conspiring to commit health care fraud and one count of aiding and abetting in a false statement relating to a health care matter.

The indictment alleges that between 2006 and April 2011, Hlushmanuk and others devised a scheme to defraud Medicare of more than $5.4 million dollars.   According to the indictment, Hlushmanuk used a straw owner to fraudulently open Starcare Ambulance because he was otherwise ineligible to own the company.   Starcare primarily transported dialysis patients and fraudulently billed Medicare for patient transport for patients who could walk and whose transportation by Medicare was not medically required.  The scheme involved transports in vans and fraudulent representations to Medicare’s administrative contractor, Highmark Medicare Services, to induce them to pay for these services.   The indictment seeks forfeiture of $5,443, 315, as well as a 2006 Hummer.

If convicted of all charges, Hlushmanuk faces a statutory maximum sentence of 10 years in prison on each of the health care fraud and conspiracy counts, five years for aiding and abetting in false statements relating to health care fraud, a three year term of supervised release, and a fine of up to $250,000.

The case was investigated by the FBI and the U.S. Department of Health and Human Services Office of Inspector General.   It is being prosecuted by Trial Attorney Sam G. Nazzaro of the Organized Crime and Gang Section in the Justice Department’s Criminal Division.

An indictment contains charges and defendants are innocent until proven guilty beyond a reasonable doubt.

107 INDIVIDUALS CHARGED IN $452 MILLION MEDICARE FALSE BILLING SCHEMES

FROM:  U.S. DEPARTMENT OF JUSTICE
Wednesday, May 2, 2012
Medicare Fraud Strike Force Charges 107 Individuals for Approximately $452 Million in False Billing

Attorney General Eric Holder and Health and Human Services (HHS) Secretary Kathleen Sebelius announced today that a nationwide takedown by Medicare Fraud Strike Force operations in seven cities has resulted in charges against 107 individuals, including doctors, nurses and other licensed medical professionals, for their alleged participation in Medicare fraud schemes involving approximately $452 million in false billing.

Attorney General Holder and Secretary Sebelius were joined in the announcement by Assistant Attorney General Lanny A. Breuer of the Justice Department’s Criminal Division, FBI Deputy Director Sean Joyce, Deputy Inspector General for Investigations Gary Cantrell of the HHS Office of Inspector General (HHS-OIG) and Dr. Peter Budetti, Deputy Administrator for Program Integrity of the Centers for Medicare and Medicaid Services (CMS).

This coordinated takedown involved the highest amount of false Medicare billings in a single takedown in strike force history.

HHS also suspended or took other administrative action against 52 providers following a data-driven analysis and credible allegations of fraud.  The new health care law, the Affordable Care Act, significantly increased HHS’s ability to suspend payments until an investigation is complete.

The joint Department of Justice and HHS Medicare Fraud Strike Force is a multi-agency team of federal, state and local investigators designed to combat Medicare fraud through the use of Medicare data analysis techniques.   More than 500 law enforcement agents from the FBI, HHS-Office of Inspector General (HHS-OIG), multiple Medicaid Fraud Control Units, and other state and local law enforcement agencies participated in the takedown.   In addition to making arrests, agents also executed 20 search warrants in connection with ongoing strike force investigations.

“The results we are announcing today are at the heart of an Administration-wide commitment to protecting American taxpayers from health care fraud, which can drive up costs and threaten the strength and integrity of our health care system,” said Attorney General Holder.   “We are determined to bring to justice those who violate our laws and defraud the Medicare program for personal gain.   As today’s takedown reflects, our ongoing fight against health care fraud has never been more coordinated and effective.”
“Today’s arrests send a strong message to criminals that the consequences of committing Medicare fraud are serious,” said HHS Secretary Sebelius.  “In addition to these arrests, we used new authority from the health care law to stop all future payments to 52 health care providers suspected of fraud before they are ever made.  Today’s actions are another example of how the Affordable Care Act is helping the Obama Administration fight fraud and strengthen the Medicare program.”

The defendants charged are accused of various health care fraud-related crimes, including conspiracy to commit health care fraud, health care fraud, violations of the anti-kickback statutes and money laundering.   The charges are based on a variety of alleged fraud schemes involving various medical treatments and services such as home health care, mental health services, psychotherapy, physical and occupational therapy, durable medical equipment (DME) and ambulance services.

According to court documents, the defendants allegedly participated in schemes to submit claims to Medicare for treatments that were medically unnecessary and oftentimes never provided.   In many cases, court documents allege that patient recruiters, Medicare beneficiaries and other co-conspirators were paid cash kickbacks in return for supplying beneficiary information to providers, so that the providers could submit fraudulent billing to Medicare for services that were medically unnecessary or never provided.  Collectively, the doctors, nurses, licensed medical professionals, health care company owners and others charged are accused of conspiring to submit a total of approximately $452 million in fraudulent billing.

“As charged in the indictments, these fraud schemes were committed by people up and down the chain of healthcare providers,” said Assistant Attorney General Breuer.   “Today’s operations mark the fourth in a series of historic Medicare fraud takedowns over the past two years.   These indictments remind us that Medicare is an attractive target for criminals.   But it should also remind those criminals that they risk prosecution and prison time every time they submit a false claim.”

“Health care fraud is not a victimless crime,” said FBI Deputy Director Joyce.  “Every person who pays for health care benefits, every business that pays higher insurance costs to cover their employees, every taxpayer who funds Medicare—all are victims.  The FBI will continue to work closely with our federal, state and local law enforcement partners to address health care vulnerabilities, fraud and abuse.  We will use every tool we have to ensure our health care dollars are used to care for the sick—not to line the pockets of criminals.”

“Today over 200 OIG Special Agents, Forensic Examiners and Analysts have deployed throughout the country to ensure that those responsible for committing Medicare fraud are held accountable,” said HHS-OIG Deputy Inspector General Cantrell.  “OIG is committed to the strike force model and will continue to use advanced data analytics along with traditional investigative methods to root out those who steal from our Medicare program.”

In Miami, a total of 59 defendants, including three nurses and two therapists, were charged today and yesterday for their participation in various fraud schemes involving a total of $137 million in false billings for home health care, mental health services, occupational and physical therapy, DME and HIV infusion.   Two of these 59 defendants were originally charged in April 2012 but were indicted on additional charges today.   In one case, 10 defendants were charged for participating in a fraud scheme at Health Care Solutions Network, which led to approximately $63 million in fraudulent billing for community mental health center (CMHC) services.   Court documents allege that therapists at Health Care Solutions Network were instructed to alter notes and other medical documents to justify CMHC services for beneficiaries who did not need the services.

Seven individuals were charged today in Baton Rouge, La., for participating in a fraud scheme involving $225 million in false claims for CMHC services.   The case represents the largest CMHC-related scheme ever prosecuted by the Medicare Fraud Strike Force.   According to court documents, the defendants recruited beneficiaries from nursing homes and homeless shelters, some of whom were drug addicted or mentally ill, and provided them with no services or medically inappropriate services.

In Houston, nine individuals, including one doctor and one nurse, were charged today with fraud schemes involving a total of $16.4 million in false billings for home health care and ambulance services.   According to court documents, the owners and operators of four different ambulance companies billed Medicare for ambulance rides that were medically unnecessary.

Eight defendants, including two doctors, were charged in Los Angeles for their roles in schemes to defraud Medicare of approximately $14 million.  In one case, two individuals allegedly billed Medicare for more than $8 million in fraudulent billing for DME.
In Detroit, 22 defendants, including four licensed social workers, were charged for their roles in fraud schemes involving approximately $58 million in false claims for medically unnecessary services, including home health, psychotherapy and infusion therapy.
In Tampa, Fla., a pharmacist was charged with illegal diversion of controlled substances.   One defendant was charged last week in Chicago for his alleged role in a scheme to submit approximately $1 million in false billing to Medicare for psychotherapy services.

The Medicare Fraud Strike Force operations are part of the Health Care Fraud Prevention & Enforcement Action Team (HEAT), a joint initiative announced in May 2009 between the Department of Justice and HHS to focus their efforts to prevent and deter fraud and enforce current anti-fraud laws around the country.

Since their inception in March 2007, strike force operations in nine locations have charged more than 1,330 defendants who collectively have falsely billed the Medicare program for more than $4 billion.

In addition, the HHS Centers for Medicare and Medicaid Services, working in conjunction with the HHS-OIG, are taking steps to increase accountability and decrease the presence of fraudulent providers.

The cases announced today are being prosecuted and investigated by Medicare Fraud Strike Force teams comprised of attorneys from the Fraud Section of the Justice Department’s Criminal Division and from the U.S. Attorneys’ Offices for the Southern District of Florida, the Eastern District of Michigan, the Southern District of Texas, the Central District of California, the Middle District of Louisiana, the Northern District of Illinois, and the Middle District of Florida, and agents from the FBI, HHS-OIG and state Medicaid Fraud Control Units.

An indictment is merely a charge and defendants are presumed innocent until proven guilty.

TENNESSEE BASED HEALTHCARE COMPANY SETTLES FALSE CLAIMS TO MEDICARE CASE

FROM:  JUSTICE DEPARTMENT
Friday, April 13, 2012
Ammed Direct Llc to Pay $18 Million to United States and Tennessee to Resolve False Claims Allegations
AmMed Direct LLC has agreed to pay the United States and the state of Tennessee $18 million plus interest to settle allegations that it submitted false claims to Medicare and Tennessee Medicaid (TennCare), the Justice Department announced today.   Under the agreement, AmMed will pay $17,560,997 to the United States and $439,003 to Tennessee.

The United States and Tennessee allege that, from September 2008 through January 2010, the Antioch, Tenn.-based company submitted false claims to Medicare and TennCare for diabetes testing supplies, vacuum erection devices and heating pads.   The United States and Tennessee asserted that AmMed widely advertised free cookbooks in order to induce Medicare beneficiaries to contact AmMed or its hired telemarketing firm.   Once AmMed confirmed that a beneficiary was covered by Medicare, AmMed representatives improperly attempted to sell the beneficiary supplies that would be paid for by Medicare.   Medicare rules prohibit medical businesses from making unsolicited telephone contact with beneficiaries to sell them their products, unless specific exceptions apply.

The United States and Tennessee further alleged that, as a result of AmMed’s improper marketing, many Medicare beneficiaries who called AmMed to receive the advertised free cookbooks returned their diabetic supplies to AmMed.   AmMed, however, failed to timely refund the money to Medicare or TennCare.   Rather, AmMed allowed the unpaid refunds to accrue from September 2006 until January 2010.   Prior to learning of the United States’ and Tennessee’s investigation, AmMed disclosed to the Medicare Administrative Contractors its failure to refund monies for returned supplies and began paying the refunds to Medicare and TennCare.

“Government health care programs have in place important rules that prohibit suppliers from improperly contacting beneficiaries regarding their products,” said Stuart F. Delery, Acting Assistant Attorney General for the Justice Department’s Civil Division.   “The Department of Justice is committed to ensuring that companies that bill government health care programs abide by those rules.”

 “Enforcement of the False Claims Act remains a top priority of this office,” said Jerry E. Martin, U.S. Attorney for the Middle District of Tennessee.   “All Medicare providers must comply with Medicare rules for reimbursement.   The U.S. Attorney’s Office for the Middle District of Tennessee will continue to devote the resources necessary to vigorously protect taxpayers’ interests and aggressively pursue fraud and abuse.”

 “We are grateful for the hard work and cooperation of our state and federal agencies in this case,” said Tennessee Attorney General Bob Cooper. “Working to stop healthcare fraud is a major priority for all of us because ultimately everyone pays for this kind of theft.”

The allegations arose from a lawsuit brought under the qui tam, or whistleblower, provisions of the False Claims Act, which permit private citizens with knowledge of false claims against the government to bring an action on behalf of the United States and to share in any recovery.   The qui tam action was filed in 2009 in federal district court in Nashville, Tenn., by former AmMed Direct employee Bryan McNeese.   The relator will receive approximately $2.88 million as his share of the settlement proceeds.

This resolution is part of the government’s emphasis on combating health care fraud and another step for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced by Attorney General Eric Holder and Kathleen Sebelius, Secretary of the Department of Health and Human Services in May 2009.   The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation.   One of the most powerful tools in that effort is the False Claims Act, which the Justice Department has used to recover more than $6.7 billion since January 2009 in cases involving fraud against federal health care programs.   The Justice Department’s total recoveries in False Claims Act cases since January 2009 are over $9 billion.

The case was investigated by the Department of Health and Human Services- Office of Inspector General (HHS-OIG), the U.S. Attorney’s Office for the Middle District of Tennessee and the Tennessee Attorney General’s Office.   The Justice Department’s Civil Division monitored the investigation.

RADIATION ONCOLOGY PRACTICE SETTLES FALSE CLAIMS CASE

FROM U.S. DEPARTMENT OF JUSTICE
Tuesday, April 3, 2012
Georgia-Based Radiation Oncology Practice to Pay $3.8 Million to Settle False Claims Act Case
WASHINGTON – Radiotherapy Clinics of Georgia LLC, a radiation oncology practice, and its affiliates RCOG Cancer Centers LLC, Physician Oncology Services Management Company LLC, Frank A. Critz, M.D. and Physician Oncology Services L.P. (collectively, RCOG) agreed to pay $3.8 million to settle claims that they violated the False Claims Act, the Justice Department announced today.  RCOG, which is located in Decatur, Ga., allegedly billed Medicare for medical treatment that they provided to prostate cancer patients in excess of those permitted by Medicare rules and for services that were not medically necessary.
           
The civil settlement resolves complaints filed by two whistleblowers, called relators, under the qui tam, or whistleblower, provisions of the False Claims Act by a former employee and a former doctor who both worked for RCOG.  The government alleged that RCOG overbilled Medicare for port films (X-ray images of the treatment area) and for simulations (the process by which radiation treatment fields are defined, filmed and marked on the skin in preparation for personalized radiation therapy).  Additionally, it was alleged that the practice overbilled Medicare for physics consults (production of complete special consultative reports for an individual patient) and for pre-plans ordered by Dr. Critz that were not medically necessary and/or never reviewed by the doctor.

“Protecting the integrity of the Medicare program, which over 47 million individuals rely on for their medical care, is one of the department’s highest priorities.  Health care providers are put on notice that they must bill only for medically appropriate care” said Stuart F. Delery, Acting Assistant Attorney General for the Justice Department’s Civil Division.

The complaints, which were filed separately by the two relators, were consolidated into the case captioned United States ex rel. R. Jeffrey Wertz and Rebecca S. Tarlton v. Radiotherapy Clinics of Georgia, LLC, et al., Civil Action No. 1:08-CV-2244, pending in the U.S. District Court for the Northern District of Georgia.  The relators, R. Jeffrey Wertz and Rebecca S. Tarlton, M.D., will receive $646,000 as their share of the proceeds.
Sally Quillian Yates, U.S. Attorney for the Northern District of Georgia, said, “This settlement demonstrates our office's continued commitment to stop Medicare fraud. Unfortunately, otherwise legitimate businesses continue to take advantage of federal healthcare programs for their private profit. We will not ignore these violations.”
“The OIG would like to remind providers that if they know a claim to be false, it is their responsibility to bill the claim properly,” said Derrick L. Jackson, Special Agent in Charge of the U.S. Department of Health and Human Services, Office of Inspector General (HHS-OIG) for the Atlanta region.  “The OIG will continue to hold companies like RCOG responsible for improper claims.”

Brian D. Lamkin, Special Agent in Charge, FBI Atlanta Field Office, stated: “The FBI continues to dedicate many investigative resources to the protection of the federally funded Medicare program from individuals who would attempt to divert these much needed funds through fraud.  The public is reminded that anyone with information regarding healthcare fraud, to include Medicare fraud, related activity should contact their nearest FBI field office.”
This resolution is part of the government’s emphasis on combating health care fraud and another step for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced by Attorney General Eric Holder and Kathleen Sebelius, Secretary of the Department of Health and Human Services in May 2009. The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation. One of the most powerful tools in that effort is the False Claims Act, which the Justice Department has used to recover more than $6.7 billion since January 2009 in cases involving fraud against federal health care programs. The Justice Department's total recoveries in False Claims Act cases since January 2009 are over $9 billion.
           
This case was investigated jointly by the Commercial Litigation Branch of the Justice Department’s Civil Division, the U.S. Attorney’s Office for the Northern District of Georgia, the FBI and HHS-OIG.