New Jersey Hospital Pays $7.5 Million for Medicare Fraud

Warren Hospital of  Phillipsburg, New Jersey, agreed to pay $7.5 million to the government for Medicare fraud. DOJ alleged that “Warren purposefully inflated charges for inpatient and outpatient care to make these cases appear more costly than they actually were, and thereby obtained outlier payments from Medicare that it was not entitled to receive.” Warren also was accused of violating the Stark laws “by submitting claims for Medicare patients referred by physicians with whom it had a unlawful financial relationship.” http://www.usdoj.gov/usao/nj/press/press/files/pdffiles/warr1210rel.pdf  

Two whistleblowers shared $1.2 million, or 16% of the recovery.

Arizona Hospital pays $5.8 million to settle Medicare Fraud claims

Source: http://www.surgicenteronline.com/hotnews/7ch10155123.html

CHARLOTTE, N.C. — MedCath Corporation (Nasdaq: MDTH) announced today that ArizonaHeartHospital, one of the 11 hospitals in which MedCath owns an interest, has entered into a settlement with the United States Department of Justice (the DOJ) and the United States Attorneys’ Office in Phoenix under the federal Civil False Claims Act.

The settlement concerns Medicare claims submitted between June 1998 and October 2002 for physician services involving the implantation of certain endoluminal graft devices (utilized to treat aneurysms) that had not received final marketing approval from the Food and Drug Administration, and allegedly were either implanted without an approved investigational device exception (IDE) or were implanted outside of the approved IDE protocol. The DOJ’s allegations related solely to whether the procedures were properly reimbursable by Medicare; quality of patient care was not an issue.

The parties reached a settlement of the allegations to avoid the delay, uncertainty, inconvenience, and expense of protracted litigation. Further, the hospital denies engagement in any wrongdoing or illegal conduct, and the settlement agreement does not contain any admission of liability. As previously disclosed in MedCath’s filings with the Securities and Exchange Commission, the hospital will pay approximately $5.8 million to settle and obtain a release from any civil or administrative monetary claims related to the DOJ’s investigation. Additionally, the hospital has entered into a five-year corporate integrity agreement with the Office of the Inspector General of the Department of Health and Human Services under which the hospital will continue to maintain its existing corporate compliance program and which relates to clinical trials conducted at the hospital.

Source: Lorin E. Patterson, Reed Smith and MedCath Corp.

Lawyer sued under False Claims Act

The DOJ has filed a false claims act suit against the former general counsel for Tenet Healthcare, previously known as National Medical Enterprises, Inc. Just last week Thomas F. O’Neil III and Melinda H. Waterhouse
of DLA Piper LP posted an excellent summary of the case.   <<http://lawfuel.com/show-release.asp?ID=16358>>

Tenet already has paid $920 million as a result of a qui tam whistleblower suit for Medicare fraud. In this suit, the DOJ is asking that the lawyer personally pay tens of millions of dollars. 

An NME executive wrote a memo suggesting that NME’s contracts with doctors violated the Stark Act.  The Stark Act is aimed at preventing kickbacks when patients are referred to a physician.  The theory behind the Stark Act is that the kickbacks ultimately get passed along to the consumer, and thus to Medicare and Medicaid.

The suit claims that the general counsel hired an outside law firm, which issued a report saying NME’s contracts with the doctors did in fact violate the Stark Act.  Nonetheless, it suggests, four days later the general counsel certified that NME was in compliance with the law, and she certified compliance again one year later.  She did ask another employee to take the corrective measures that the outside firm had suggested, but, per the suit, apparently she never followed up. 

I’ve been saying all along that healthcare professionals, billing department employees, nurses, etc., have got to protect themselves.  In a corporate environment, it’s easy to buy into “group think” – the company makes all the decisions, you just do what you’re told to do.  But this case certainly makes it clear how dangerous an assumption that is.  Nobody in the healthcare field, regardless of whether they are giving direct medical care, should make that assumption.  If you know about fraud, don’t put yourself in a spot to take the heat for it. 

Department of Defense Inspector General finds Contractor Fraud in Iraq

It appears that qui tam and whistleblower cases in the Department of Defense area are bound to take off.

The DOD Inspector General has issued a report on what it calls “challenges” to keeping up with the supplies for our troops and for distribution in Iraq. 

http://www.dodig.mil/Audit/reports/fy08/08-026.pdf

The IG said it had “identified a large amount of equipment that was unaccounted for,” but that “it would not be feasible or prudent to request MNSTC-I to continue to try to account for that equipment.”  But it’s the specifics that tell the tale – like the fact that they couldn’t account for 12,712 of 13,508 weapons that were supposed to be delivered. And like this terrifying sentence: “We were unable to identify an audit trail for 99 percent of equipment MIPRs, worth $438.2 million.”

Yikes!  You like to think that it was just a matter of poor procedure controls – that none of these weapons walked off into enemy hands, and that none of the suppliers took advantage of the confusion to ship just part of what they had promised.

But how can you know?  And that’s the point of the report. 

In her blog, Dina Rasor reminds us of the fraud that came to light in the 1980’s.  http://www.huffingtonpost.com/dina-rasor/outraged-at-the-billion-d_b_75707.html

Good point.  Who could forget the $600 toilet seats?

As an interesting aside, I tried to find out just how much those toilet seats did cost.  I gather that the story has moved into the halls of urban myth by now, because folks cite prices from $600 to $40,000.  Either way, it’s more than I pay at Home Depot.

But back to the question – who could forget the toilet seats?  We could, that’s who. 

Let’s hope there are some folks out there who will blow the whistle if fraud did occur.  I personally don’t want to pay my tax share of $438.2 million. 

Northern District of Georgia recovers 14.1 million from civil debtors in fiscal year 2007

According to the United States Attorney for the Northern District, David E. Nahmias, the government recovered $14.4 million from civil debtors in fiscal year 2007 (which ended on September 30, 2007). 

Some of the larger collections were: the Morehouse Medical Associates, Inc. settlement ($1.525 million); the Northside Hospital qui tam settlement ($6.3 million) and the collection matter of United States v. David T. Kent ($500,000). 

Federal government recovers $1.45 billion thanks to whistleblowers who protect the government against fraud

According to a press release issued by the Department of Justice, in 2007, the United States recovered $1.45 billion in suits initiated by whistleblowers under the False Claims Act's qui tam provisions. 

Relators were awarded $177 million for their work in stopping fraud against the United States government.  Whistleblower relators get 15 to 25 percent of the proceeds if the United States intervenes, and up to 30 percent if the United States declines and the relator pursues the action alone. 

Peter D. Keisler, Acting Attorney General and Assistant Attorney General for the Civil Division, said: “It also attests to the fortitude of whistleblowers who report fraud and the tireless efforts of the civil servants who investigate and prosecute these cases.”

Health care fraud accounted for the largest percentage of the judgments -- $1.54 billion. “This number includes both whistleblower claims and those initiated by the United States in independent fraud investigations.”  The biggest recoveries were for fraud against the Department of Health and Human Services, largely under Medicare and Medicaid programs. The government also recovered for fraud against the Office of Personnel Management, which administers the Federal Employees Health Benefits Program, the Department of Defense for its TRICARE insurance program, the Department of Veterans Affairs, and others.

http://www.usdoj.gov/opa/pr/2007/November/07_civ_873.html

Bristol-Myers Squibb Co., Aventis Pharmaceuticals, Inc., Medco Health Solutions, Inc., Purdue Pharma L.P. and Purdue Frederick Co., and InterMune, Inc. paid more than $800 million of the $1.5 billion.  State Medicaid programs also recovered $264 million for pharmaceutical fraud.

The government touted its “Department-wide effort” to stop fraud in the pharmaceutical industry. “Typical allegations involve illegal promotion of drugs or devices and causing the government to pay for uses that were neither found by the Food and Drug Administration to be safe and effective, nor supported by the medical literature, also known as “off-label” marketing; paying kickbacks to physicians, wholesalers, and pharmacies to induce drug or device purchases; establishing inflated drug prices knowing that federal health care programs use these prices to reimburse providers, then marketing the “spread” between the federal reimbursement and the provider’s lower cost to induce drug purchases; and failing to report the company’s true “best price” for a drug to reduce rebates owed to the Medicaid program.”  http://www.usdoj.gov/opa/pr/2007/November/07_civ_873.html

Recoveries for other agencies:

Department of Defense: $48.4 million 

General Services Administration: 

Burlington Resources, Inc., a subsidiary of Conoco Phillips, paid $105.3 million based on claims that it had underpaid natural gas royalties to the Department of Interior. Oracle Corporation paid $98.5 million to resolve allegations that PeopleSoft, Inc. (acquired by Oracle in 2005) engaged in defective pricing of its software and services under the company’s multiple award schedule with GSA. Mellon Bank, N.A. paid $34.6 million to settle claims that it violated its contract with the Internal Revenue Service to process individual income tax returns and payments.

Trials:

The Department of Justice tried two whistleblower cases, and won both. 

(1) $172 million judgment against Amerigroup, Illinois Inc.   Whistleblowers alleged that Amerigroup’s HMO in Illinois illegally increased its profits by discriminating against pregnant women and individuals with pre-existing medical conditions when enrolling Medicaid-eligible applicants.  Amerigroup is appealing. 

(2) $90 million judgment against several companies for conspiring to rig bids on contracts financed by the U.S. Agency for International Development for the construction of wastewater treatment facilities in Cairo, Egypt.

http://www.usdoj.gov/opa/pr/2007/November/07_civ_873.html

Northside Hospital and other defendants pay over $ 6 million to settle Medicare Fraud claims

In February 2004, Cheryl Burns and Janine Slaughter filed a qui tam suit under the False Claims Act.  The False Claims Act allows citizens to sue on behalf of the United States when false claims that are knowingly submitted to government programs. The United States can recover triple damages and civil penalties, and the whistleblowers receive a percentage of the recovery.  

Ms. Burns and Ms. Slaughter had both worked for the Blood and Marrow Transplant Group of Georgia (“BMTGG”), Ms. Burns as a CEO and Ms. Slaughter as a billing/office manager. The women alleged that BMTGG and Northside Hospital had violated the Social Security Act provisions known as the Stark Law. Under the Stark law, a physician cannot make a referral to an entity for the furnishing of certain health services, if that physician has a financial relationship with the entity that does not meet one of the law’s exceptions. 

 

Ms. Burns and Ms. Slaughter alleged that BMTGA, in affiliation with Northside Hospital, operates a clinical transplant program for stem cell transplants and cancer treatment.  The transplant physicians who own BMTGA also own ABS (formerly known as Atlanta Blood Center), which is a clinical laboratory that provides services and blood products to Northside Hospital. 

According to the allegations, Northside provided employees to the physicians, free of charge, for the benefit of the physicians’ private practice.  They also alleged that Northside Hospital had purchased platelet products from Atlanta Blood Center at an inflated price.  The Government added a claim that Northside was paying medical directorship fees to the transplant physicians that exceeded fair market value. According to the allegations, all of these charges then were passed through to the government through Medicare claims made by the hospital.    

The United States agreed to dismiss the lawsuit.  In exchange, the three entities agreed to pay $6,378,448.00, and to execute Certification of Compliance Agreements with the Department of Health and Human Services, Office of Inspector General.  Under the Compliance Agreements, the hospital and physicians’ group are required to 

adhere to certain policies and procedures to ensure compliance with applicable statutes 

and regulations.  

Northside Hospital in Atlanta agreed to pay approximately $5.72 million, and BMTGA and Atlanta Blood Services (ABS), agreed to pay $650,000.

Ms. Burns and Ms. Slaughter jointly received $1.2 million as their share of the recovery under the settlement. 

Assistant United States Attorney Mina Rhee handled the case for the United 

States.  

Piedmont Hospital agrees to pay over $3 million to resolve a False Claims Act case

In July 2003, Patricia J. Quinnelly, filed a “whistleblower,” or “qui tam” suit against Piedmont Hospital.  Quinnelly was a vascular technologist in Piedmont’s F. Levering Neely Vascular Laboratory from 2001 through 2004. 

Ms. Quinnelly filed suit under the False Claims Act, 29 U.S.C. § 3729 et seq.  That act allows the United States to recover triple damages and civil penalties when false claims are knowingly submitted to government programs. 

Quinnelly alleged that “Piedmont Hospital had submitted claims for a physician’s interpretation of some vascular laboratory tests when the physician interpretation, in fact, had not been done.  Specifically, Quinnelly alleged that one of the laboratory’s physicians routinely failed to conduct an independent review of the vascular test data, and instead simply signed off on the technicians’ interpretations and proposed diagnoses.” http://www.usdoj.gov/usao/gan/press/2006/06-09-06.pdf  

During the investigation of Ms. Quinnelly’s claims, the government discovered that Piedmont Hospital also had failed to execute contractual agreements with the physicians performing services at the vascular laboratory.  The Stark law, 42 U.S.C. §1395, a Social Security Act provision, regulates physicians’ referrals to entities in which they have a financial interest. 

The United States agreed to dismiss the lawsuit in exchange for $3,039,388.00 

“and Piedmont’s acceptance of a Certification of Compliance Agreement entered into with the Department of Health and Human Services, Office of Inspector General.  The 

Compliance Agreement requires Piedmont to adhere to certain policies and procedures to ensure compliance with applicable statutes and regulations that govern the use of federal health care funds.”   http://www.usdoj.gov/usao/gan/press/2006/06-09-06.pdf

Quinnelly received $354,390.00 as her share of the recovery under the settlement. 

Clark Atlanta University pays $5 million to settle whistleblower suit

Clark Atlanta University has agreed to pay $5 million to settle a  federal 

whistleblower, or qui tam, suit, brought by Dr. August Curley.

“The lawsuit alleged that Clark Atlanta, acting as manager of a Consortium that included itself and sixteen other universities, received and retained approximately $24 million under a Cooperative Agreement that Clark Atlanta had with the Department of Energy.” http://www.usdoj.gov/usao/gan/press/2006/04-14-06.pdf   Dr. Curley was hired by Clark Atlanta as Program Manager for the Consortium in 1995.

 

“The Consortium was created in 1990 to meet the Department of Energy’s anticipated needs for a workforce of scientists and engineers trained in environmental technology, environmental restoration, environmental health and waste management.  The complaint alleged that under the terms of the Cooperative Agreement, Clark Atlanta was to use the funds for very specific purposes designed to further the goal of training a minority workforce in environmental sciences, but that Clark Atlanta did not in fact use the funds for those purposes.” http://www.usdoj.gov/usao/gan/press/2006/04-14-06.pdf

Clark Atlanta also agreed to enter into a Compliance Agreement designed to ensure that future federal funds will be managed appropriately. 

Dr. Curley received 22% of the $5 million, or $1.1 million.  “The remaining $3.9 million, plus interest, will be paid to the United States in installments over five years.” http://www.usdoj.gov/usao/gan/press/2006/04-14-06.pdf

 

Life Care Centers group pays $2.5 million to resolve whistleblower suit

Life Care Centers of America, Inc. (LCCA), the operator of a skilled nursing facility located in Lawrenceville, Georgia known as Life Care Center of Lawrenceville (Lawrenceville), along with Gwinnett Operations, a TN LLC, successor to Gwinnett Medical Investors Limited Partnership (GO), Developers Investment Company, Inc. (DIC) and Forrest L. Preston, the owners of Lawrenceville, agreed to pay $2.5 million to resolve multiple allegations that Lawrenceville had violated the federal False Claims Act by billing for services that either were not provided or were worthless to the Lawrenceville residents.

In November 2002, five whistleblowers, who were family members of Lawrenceville residents, filed a qui tam suit.  They alleged a systemic failure in the care rendered to residents at Lawrenceville.  Lawrenceville had failed to provide appropriate nursing care, resulting in the premature deaths of several residents, according to the allegations.  “The whistleblowers' complaint alleged that the failure of care was the result of severe understaffing, inadequate staff training, high staff turnover, an ineffective medical director, poor nursing documentation, and insufficient budgetary allowances.” http://www.usdoj.gov/usao/gan/press/2005/12-22-2005.html

The United States and the State of Georgia have agreed to dismiss the lawsuit in exchange for a total payment of $2.5 million, with the United States receiving $1,092,000 for damages sustained by the Medicare program and $604,800 for the federal share of the damages sustained by the Medicaid program. The State of Georgia received $403,200 for the damages sustained by the State of Georgia in connection with its funding of the Medicaid program. 

Three of the whistleblowers remained parties to the suit at the conclusion of the case, and they received a total of $400,000. 

LCCA and Lawrenceville also agreed to enter into a Corporate Integrity Agreement (CIA), requiring Lawrenceville to continue to implement certain policies and procedures to ensure compliance with applicable statutes and regulations governing patient care.  The Agreement also provided for the appointment of an independent monitor who will oversee operations at Lawrenceville for up to five years to verify that its policies and procedures are working effectively and that patients receive appropriate care.  LCCA also voluntarily agreed to apply the policies and procedures implemented for Lawrenceville to LCCA's other facilities across the country.

Peter D. Keisler, Assistant Attorney General for the Civil Division, said that the settlement was " the largest recovery against a single skilled nursing facility under the False Claims Act based on a failure of care case to date." http://www.usdoj.gov/usao/gan/press/2005/12-22-2005.html

United States Attorney David E. Nahmias said, "This case demonstrates that the government will not tolerate a nursing home's failure to provide adequate care to the elderly, our most vulnerable citizens; and that the government will continue to ensure that public funds expended on behalf of nursing home residents are used appropriately to provide them with adequate care and services. While we always expect to recover the public funds improperly expended, in these nursing home cases, our primary goal is to ensure good patient care. Life Care's willingness to voluntarily apply the policies and procedures implemented at Lawrenceville to its other facilities helps further this goal." http://www.usdoj.gov/usao/gan/press/2005/12-22-2005.html

Georgia Attorney General Thurbert Baker said, "Today's settlement reaffirms the commitment of both the State of Georgia and the federal government to pursue allegations of improper care provided to Georgia's elder citizens. In failing to provide sufficient care for these nursing facility residents, Life Care placed at risk the very residents who had been entrusted to its care. This settlement sends a clear message that taking shortcuts to improve the financial bottom line in the medical arena will have legal consequences."  http://www.usdoj.gov/usao/gan/press/2005/12-22-2005.html