United States: OIG Enforcement Summary: July 16, 2022 – July 31, 2022

PA. The Defendant, skilled nursing facility, agreed to settle allegations that the Defendant overbilled Federal healthcare programs (like Medicare) for therapy services provided; billed for services not provided; billed for unreasonable, unnecessary, and sometimes harmful therapy; and allowed a therapy provider to manipulate clinical services to maximize billing. Medicare Part A paid for SNF services at a daily rate based in part on a Resource Utilization Group (RUG) to which the Medicare beneficiary was assigned. The Defendant allegedly cause the submission of false claims for Ultra High RUG therapy levels despite evidence that the RU level of therapy was not reasonable or necessary for the respective patients.

This matter was initiated by a Qui Tam case.

FL. The Defendant, personal support services provider, allegedly submitted fraudulent billing claims to Medicaid for hours not worked along with service logs that did not match the hours billed or were absent entirely.

NJ. The Defendant, Mallinckrodt ARD, LLC, as part of its federal and multi-state Medicaid settlement of fraud allegations for underreporting drug rebates agreed to a financial settlement with NJ. Underpayment of rebates allegedly violated the FCA and the NJ FCA.

The federal and multi-state Medicaid action was initiated through a Qui Tam action.

MA. The Defendant, specialty pharmacy, agreed to resolve allegations that it altered patient medical records and submitted the altered medical records to Medicare in support of prior authorization request. The Defendant agreed that without express authorization from the prescribing physician, it removed certain information in supporting documentation associated with the specific drugs in issue that needed a prior authorization request.

TN. The Defendant, dentist and his affiliated companies, agreed to settle allegations that they knowingly and improperly submitted false claims for dental services to Medicaid when one of the companies falsely identified the Defendant-dentist as the rendering provider when the actual dentist was uncredentialed and therefore ineligible to bill Medicaid. In TN being credentialed as a dental provider is a condition for Medicaid payment.

The case was initiated through a Qui Tam complaint.

NY. The Defendant allegedly ran a company "dedicated to illegally buying written orders for" DME and then selling those written orders to DME supply companies, which used those orders to file fraudulent Medicare claims. The Defendant allegedly violated the AKS when he bought and sold written orders, many of which used names and personal health information of Medicare beneficiaries, without the beneficiaries' authorization or prior knowledge; and contained professional information of doctors and other healthcare providers enrolled in Medicare, as well the purported electronic signatures of the providers which were falsified and created without the authorization or knowledge of the providers.

NJ.

DOJ. The Defendants, clinical laboratories and their owners, agreed to settle allegations that they submitted false claims to Medicare by paying kickbacks in return for genetic testing samples. The Defendants allegedly used various marketers to solicit genetic testing samples from Medicare beneficiaries, the marketers had physicians fraudulently attest that the genetic testing was medically necessary, and the Defendant-labs would process the tests and receive Medicare payments which were shared with the marketers. To conceal the kickbacks, the Defendants entered into sham agreements with marketers to provide various consulting, marketing and other services at an hourly rate, but the Defendants paid the marketers a percentage of the revenue, including Medicare reimbursement, in return for the samples. The marketers generated sham invoices for hourly services that matched the agreed-upon kickback amount.

DOJ. The Defendant, a medical device manufacturer, agreed to resolve allegations that it violated the FCA by paying kickbacks to physicians to induce use of Defendant's implantable cardiac devices (e.g., pacemakers and defibrillators). The Defendant allegedly used kickbacks to pay certain favored physicians to induce and reward their use of Defendant's devices. The Defendant allegedly abused new employee training programs by paying physicians for an excessive number of trainings and, in some cases, for training events that either never occurred or were of little or no value to trainees. The payments were allegedly made despite concerns raised by the Defendant's compliance department which warned that salespeople had too much influence in selecting physicians to conduct new employee training and that training payments were being overused. The settlement also resolves allegations that the Defendant violated the AKS when it paid for physicians' holiday parties, winery tours, lavish meals with no legitimate business purpose and international business class airfare and honoraria in exchange for making brief appearances at international conferences.

TX. 36 Defendants allegedly participated in fraudulent telemedicine, cardiovascular and cancer genetic testing and DME schemes. 21 individuals (doctors, laboratory executives, hospital executives and marketers) were charged for their involvement in healthcare kickback and money laundering conspiracies. Additionally, 33 doctors and healthcare executives agreed to pay over $32 million to resolve FCA allegations for their involvement in the scheme. The criminal and civil cases allege the Defendants unlawfully enriched themselves by paying and receiving illegal kickbacks in exchange for laboratory referrals.

Physicians were allegedly incentivized to make referrals to critical access hospitals and an affiliated lab in exchange for kickbacks that were disguised as investment returns. Marketers were incentivized to order, arrange for, or recommend the ordering of services from critical access hospitals and an affiliated lab in violation of the AKS.

Critical access hospitals partnered with a clinical laboratory where the clinical lab's blood tests were billed by the hospitals as outpatient services with the hospitals charging insurers a much higher rate than the clinical lab could receive. The hospitals used a network of marketers to operate MSOs that offered investment opportunities to physicians which were really payments for physician referrals. The clinical lab gained and increased referrals it received through this scheme.

CA. Defendant owned and controlled, with her husband, home health care and hospice agencies, and the two certified to Medicare that they would not pay kickbacks in exchange for Medicare beneficiary referrals to their agencies. Despite the certifications the Defendant paid and directed others to pay kickbacks to multiple individuals for referrals, including employees of health care facilities, and employees' spouses.

TN. Defendant, physician in an alleged telemedicine conspiracy, allegedly worked for telemedicine companies that arranged for physicians to prescribe a variety of DME, topical creams, and Cancer Genomic testing for Medicare beneficiaries. He and his co-conspirators allegedly paid and received kickbacks and bribes in exchange for signed doctors' orders and prescriptions, which were submitted to Medicare for services and treatments that were not medically necessary and not eligible for reimbursement. The Defendant allegedly signed doctors' orders electronically without having established a required patient/doctor relationship, and issued orders and prescriptions based on only a brief telephonic conversation, or often with no conversation at all and without seeing or physically examining the patient, and without considering medical necessity for the treatment prescribed. The Defendant was allegedly paid by telemedicine companies a "per visit" fee which constituted illegal kickbacks and bribes.

MA. Defendant, clinical laboratory provides anatomic pathology services to physician practices, admitted that it routinely and automatically conducted additional tests on biopsy specimens prior to a pathologist's review and without an individualized determination that the additional tests were medically necessary. The Federal government contended this practice resulted in performance of many tests that were medically unnecessary that were submitted to Federal healthcare programs for payments as false claims.

The matter was initiated by a Quit Tam case.

NC. Defendant, physician assistant, allegedly worked as an independent contractor for a physician staffing and telemedicine company. During that time, he allegedly signed fraudulent prescriptions for medically unnecessary genetic testing, specifically cancer genomic and pharmacogenetic testing for Medicare beneficiaries. The Defendant allegedly never met, saw or treated these beneficiaries, and had only brief telephone conversations with them, or no interactions with beneficiaries whatever. The indictment alleges that the Defendant falsified medical records in connection with the prescriptions to conceal that he was not the treating physician and that he did not conduct medical evaluations or examinations, and that he falsely certified that the tests were medically necessary. Contrary to his claims, the indictment alleges the Defendant had neither pre-existing provider-patient treatment relationships with, nor plans to pursue further care for the Medicare beneficiaries. It is alleged that the telemedicine company and its clients provided the Defendant with pre-populated prescription forms and related records for patients who were pre-selected for genetic testing, which the Defendant electronically signed and returned.

SC. Defendant, owner and operator of Clearscreen LLC, allegedly obtained more than $10,000 with intent to cheat and defraud the SC Medicaid program. The Defendant also allegedly took part in creating and submitting fraudulent documents and claims to SC Medicaid for mental health services not rendered to numerous Medicaid beneficiaries.

AZ. Defendants, physician and his PC, entered into a settlement agreement with OIG to resolve allegations that the Defendants submitted claims to Medicaid for facet joint injections and denervations that exceeded the allowable number of sessions in a rolling 12-month period.

CIVIL MONETARY PENALITIES AND AFFIRMATIVE EXCLUSIONS REPORT

CA. Defendant, pain specialist, agreed to settle allegations that he prescribed specific medications manufactured by Purdue and Depomed Inc. in exchange for payments for speaking and consulting work, which payments violate the AKS. As such the associated claims to Federal healthcare programs are rendered false.

MA. Defendant, owner of a behavioral health clinic, pled guilty for allegedly billing for substance use disorder and/or mental health services she did not perform either because she was incarcerated or out of the country; billing for services not rendered by licensed or supervised employees; and billing for services under the name and number of providers who no longer worked for her clinic and who did not provide the services. She allegedly received payment from private insurers for services not rendered. The Defendant was also arraigned on additional charges in connection with billing Medicare for false claims for services not rendered.

ID. Defendant pled guilty in April for allegedly billing Medicaid for services she did not provide. It was determined that the services were provided while the Defendant was out of state on several occasions and billed for services to a family member in ID at the same time.

NJ. Defendant entered into a settlement agreement with OIG to resolve allegations that it failed to submit timely certified monthly and quarterly Average Manufacture's Price (AMP) data to CMS for certain months and quarters in 2021. The Medicaid Rebate Program requires the reports.

CIVIL MONETARY PENALITIES AND AFFIRMATIVE EXCLUSIONS REPORT

OH. Defendants, physician and his LLC, entered into a settlement agreement with OIG to resolve allegations that Defendants submitted claims for monitored anesthesia care in conjunction with intraarticular facet joint injections or medial branch blocks where such monitored anesthesia care was routinely billed, which is not covered by Medicare Part B.

CIVIL MONETARY PENALITIES AND AFFIRMATIVE EXCLUSIONS REPORT

NY. Defendant, ambulance firm, entered into a settlement agreement with OIG to resolve allegations that Defendant submitted claims to Medicare Part B for ambulance transportation to and from SNFs where such transportation was already covered by the SNF consolidated billing payment under Medicare Part A.

CIVIL MONETARY PENALITIES AND AFFIRMATIVE EXCLUSIONS REPORT

IL. Defendant, physician, entered into a settlement agreement with OIG to resolve allegations that Defendant received remuneration from a telemedicine company in form of monetary payments related to purported telemedicine and diagnostic consultations. The Defendant allegedly solicited and received the remuneration in exchange for ordering DME that was paid for by Medicare.

CIVIL MONETARY PENALITIES AND AFFIRMATIVE EXCLUSIONS REPORT

GA. Defendants, physician and his LLC, entered into a settlement agreement with OIG to resolve allegations that Defendant submitted claims to Medicare for facet joint injections and denervations that exceeded the allowable number of sessions in a rolling 12-month period.

CIVIL MONETARY PENALITIES AND AFFIRMATIVE EXCLUSIONS REPORT