NJ Pathology Practice to Pay $2.4 Million to Resolve False Claims Act Violation Allegations

Princeton Pathology Services P.A., a New Jersey pathology practice, reached a Settlement Agreement with the U.S. Department of Justice (DOJ) and agreed to pay the U.S. government $2.4 million to resolve allegations that it violated the False Claims Act, announced Acting U.S. Attorney Rachael A. Honig on Dec. 7, 2021.

The civil settlement resolves allegations that arose from a lawsuit filed under the whistleblower provisions of the False Claims Act. The whistleblower will receive $456,000 as a part of the federal share of the settlement.

Medicare whistleblower lawyers at Khurana Law Firm, P.C. support reporting fraud and abuse in the healthcare industry and offer help building a strong case that can result in the whistleblower receiving a reward for aiding the government in fighting fraud.

What Alleged Violations did Princeton Pathology Commit?

According to the DOJ’s contentions in the settlement agreement, Princeton Pathology allegedly made false representations in connection with submissions to the Centers for Medicare & Medicaid Services (CMS) under Current Procedural Terminology (CPT) between Jan. 1, 2015, and Dec. 31, 2020.

Princeton Pathology failed to provide written support in medical records despite the CPT code requiring written analysis by a pathologist. As a result, Princeton Pathology billed Medicare for analysis of tests while no such analyses were required or done, causing Medicare to significantly overpay.

“Submitting claims for unsubstantiated services threatens the integrity of the Medicare program and will not be tolerated,” said Scott J. Lampert, HHS-OIG Special Agent in Charge. “We will continue to protect patients and taxpayers by holding accountable providers who endanger the integrity of federal health care programs and the beneficiaries they serve.”

What was the Whistleblower’s Role in the Princeton Pathology Case?

The case was initiated by a qui tam complaint filed under the False Claims Act, which permits private parties to sue for false claims on behalf of the United States and to share in any recovery.

The whistleblower Jayant Barai, M.D. who is an internal medicine specialist from Orange, NJ, will receive $456,000 of the settlement amount for providing information that led to the case.

The DOJ’s pursuit of the Princeton Pathology lawsuit illustrates the government’s efforts to combat healthcare fraud and Dr. Barai’s assistance played a crucial role in building a strong case thus helping to defraud federal healthcare programs.

How Can Whistleblowers Help Fight Fraud in the Healthcare System?

Health care fraud has been causing tens of billions of dollars in losses each year and threatening the integrity of the Medicare program underlined DOJ representatives and encouraged persons with non-public information regarding medical system violations to report the abuse.

Medicare whistleblower lawyers at Khurana Law Firm, P.C., support the decision to come forward to report abuse and fraud in the healthcare industry. If you have become aware of a fraud or abuse scheme, you may be able to act as a whistleblower.

The national whistleblower attorney Arvind Bob Khurana helps whistleblowers build a strong case and receive a reward for aiding the government in fighting fraud. Contact us today for a consultation. For a free, confidential evaluation call (888) 335-5107

source https://medicarewhistleblowercenter.com/nj-pathology-practice-to-pay-2-4-million-to-resolve-false-claims-act-violation-allegations/

Pharmacist and Two Pharmacies to Pay $1 Million False Claims Act Settlement

Michigan-based pharmacist Riad Zahr and two specialty pharmacies that he previously owned have agreed to pay the U.S. $1 million to resolve allegations of false claims for an anti-overdose drug, informed the US Department of Justice (DOJ) in their press release on Dec. 8, 2021.

The civil settlement came as a result of the allegations presented by the whistleblower, who is awarded $200,000 of the government’s recovery as part of the settlement.

Medicare whistleblower lawyers at Khurana Law Firm, P.C. support reporting abuse in the healthcare industry and encourage anyone with non-public information regarding medical system violations to help expose the fraud.

What Alleged Violations did Mr. Zahr Commit?

The DOJ alleged that Plymouth Towne Care Pharmacy dba People’s Drug Store (People’s Drug Store) and Shaska Pharmacy LLC dba Ray’s Drugs (Ray’s Drugs) submitted false claims for the drug Evzio to Medicare between August 1, 2017 and June 30, 2019.

Evzio (naloxone hydrochloride injection) was the highest-priced version of naloxone drug on the market used to reverse opioid overdose. Due to its price, the insurance companies are required to submit prior authorization requests before approving to cover for Evzio.

“The government alleged that People’s Drug Store and Ray’s Drugs submitted false and misleading prior authorization requests for Evzio that contained clinical assertions for which the pharmacies lacked any factual basis,” the press release states.

The $1 million settlement resolves DOJ claimed that Mr. Zahr and the two pharmacies initiated Evzio prescriptions based on rudimentary patient lists with only basic biographical details.

What is the Whistleblower’s role in Mr. Zahr Case?

The allegations resolved by the civil settlement were initially brought up under qui tam or whistleblower provisions of the False Claims Act by the whistleblower Rebecca Socol. Mrs. Socol, who formerly worked for kaléo Inc., the manufacturer of Evzio, will receive $200,000 of the settlement amount for her involvement and the provided information which led to the case.

In Nov., 2021, Mrs. Socol received $2,548,600 when kaléo Inc. made a $12.7 million settlement with the DOJ, which resolved the allegations that the company “caused the submission of false claims” for Evzio.

What is the DOJ’s Stand in the Riad Zahr Case?

“Taxpayers pay a huge amount of money for federal health care programs, and they expect that money will be spent honestly and effectively,” said Acting U.S. Attorney Nathaniel R. Mendell for the District of Massachusetts commenting on the settlement in Mr. Zahr’s case. “Our job is to find and stop misconduct like this, which hurts those programs and cheats us all.”

Whistleblowers are the government’s first line of defense in the fight against fraud in the healthcare industry when it comes to Medicare. If you have the information that can help defraud the Medicare program, you may be able to act as a whistleblower.

The national whistleblower attorney Arvind Bob Khurana helps people to build a strong case that helps whistleblowers receive a reward for aiding the government to fight fraud. Contact us today for a consultation. For a free, confidential evaluation call (888) 335-5107

source https://medicarewhistleblowercenter.com/pharmacist-and-two-pharmacies-to-pay-1-million-false-claims-act-settlement/

Miami Clinic Owner Charged with $38M Healthcare Fraud

Armando Valdes, the owner and operator of a medical clinic in Miami, Florida, was arrested on Dec. 10 and charged with submitting approximately $38 million in fraudulent health care claims to United Healthcare and Blue Cross Blue Shield (BCBS), according to the US Department of Justice (DOJ).

Valdes ran Gasiel Medical Services, Corp. in Miami-Dade County, and allegedly benefited from submitting false claims to major private insurers for supposedly treating patients from arthritis, inflammations, and ulcers.

How did Gasiel Medical Services Operate?

Mr. Valdes allegedly falsely billed United Healthcare and BCBS for medically unnecessary infusions of Infliximab, known by the brand name Remicade, through his medical clinic Gasiel Medical Services. Remicade is an expensive prescription immunosuppressive drug used to treat several autoimmune diseases. The medication was not provided to patients as billed.

“The indictment alleges that United and Blue Cross paid Gasiel nearly $8 million as a result of the fraudulent claims for Infliximab submitted by Valdes,” reads the press release published by the DOJ.

Gasiel Medical Services owner allegedly ran his scheme from Feb. 2015 to July 2021 and is now charged with 10 counts of health care fraud as the Federal Government is stepping up the crackdown on alleged fraud in the healthcare industry.

The 10 counts of health care fraud each carry a maximum of 10 years per count, making the maximum sentence faced by Mr. Valdes up to 100 years in prison if convicted, according to the Justice Department.

How did Mr. Valdes Spend the Proceeds?

The DOJ investigation uncovered that Mr. Valdes spent millions of dollars made through false claims on Florida properties.

“According to the indictment, Valdes used his ill-gotten proceeds to purchase four real estate properties, including a beachfront condo in Pompano Beach, as well as luxury vehicles including a Cadillac Escalade and a Tesla Model S,” the press release reads.

The records showed that the clinic owner purchased a three-bedroom condo at Sabbia Beach, a one-bedroom Aventura ParkSquare unit, a four-bedroom house in Estero, and a four-bedroom home and adjacent lot in Sebring all worth nearly $2.2 million. Another nearly $1.7 million were put on his business and personal bank accounts. Federal prosecutors plan to seize all assets belonging to Mr. Valdes.

How Can Whistleblowing Help Prevent Healthcare System Fraud?

Health care fraud affects everyone and causes tens of billions of dollars in losses each year. The US federal agencies encourage persons with non-public information regarding medical system violations to help expose the health care fraud.

At Khurana Law Firm, P.C., top-notch Medicare whistleblower lawyers support the decision to come forward to report abuse and fraud in the healthcare industry.

If you have become aware of a fraud or abuse scheme, you may be able to act as a whistleblower. The national whistleblower attorney Arvind Bob Khurana helps people to build a strong case that has helped whistleblowers receive a reward for aiding the government to fight fraud. Contact us today for a consultation. For a free, confidential evaluation call (888) 335-5107

source https://medicarewhistleblowercenter.com/miami-clinic-owner-charged-with-38m-healthcare-fraud/

Oak Street Health under Federal Investigation

The US Department of Justice (DOJ) is investigating Chicago-based Oak Street Health, a value-based primary care network for adults on Medicare, for possible violations of the False Claims Act according to the regulatory filing published on Nov.8.

The DOJ requested the healthcare facility to provide information related to the company’s free transportation for Medicare patients, as well as about its relationships with third-party marketing agents as the Federal Government is stepping up the crackdown on alleged fraud in the Medicare Advantage program.

How does Oak Street Health Operate?

The Oak Street inquiry is one of the many recent cases where the Federal Government is trying to establish whether the health provider violated the False Claims Act. The DOJ has been recording an increase in fraud and abuse as the Medicare Advantage plans have taken on a larger role in the Medicare program.

Since Oak Street has risk-based contracts with Medicare Advantage plans, its main revenue source comes from the Centers for Medicare & Medicaid Services (CMS) direct contracting program. In this way, the primary care company takes full responsibility for patients’ medical expenses while the Federal Agency provides the fixed per-patient monthly payment.

What Alleged Violations did Oak Street Health Commit?

According to the Oak Street Health representatives, the DOJ sent a civil investigative demand on Nov. 1 asking the company to provide information about their relationships with third-party marketers and transportation partners.

The civil investigative demand issued by the DOJ does not signify any form of legal action but is rather a request to provide documents or evidence that could be used by the Government to start an investigation into the potential False Claims violations. The actual investigation would determine whether there’s sufficient evidence to warrant filing an action.

Why is Whistleblowing Important for the Medicare System?

Government agencies encourage persons with non-public information regarding the Medicare and Medicaid system violations to help uncover fraud. At Khurana Law Firm, P.C., Medicare whistleblower lawyers, support the decision to share any relevant information and report abuse and fraud in the healthcare industry.

If you have become aware of a fraud or abuse scheme, you may be able to act as a whistleblower. The national whistleblower attorney Arvind Bob Khurana helps people to build a strong case that has helped whistleblowers receive a reward for aiding the government to fight fraud. Contact us today for a consultation. For a free, confidential evaluation call (888) 335-5107.

source https://medicarewhistleblowercenter.com/oak-street-health-under-federal-investigation/

Federal Government Asks to Join $800 Million Whistleblower Lawsuit Against Methodist Hospital

The federal government filed a motion to join a whistleblower lawsuit against Methodist Hospital to recover damages caused by the alleged multi-million-dollar health care program’s fraud scheme.

Medicare whistleblower lawyers at Khurana Law Firm, P.C. support the decision to come forward to report abuse and fraud in the healthcare industry.

The government’s motion comes nearly four years after the original lawsuit was filed by Jeff Liebman, the Methodist University Hospital’s former CEO, and Dr. David Stern, the former Vice Chancellor for University of Tennessee Health Science Center. The whistleblowers claimed that Methodist knowingly defrauded federal and state healthcare programs, including Medicare and Medicaid, and caused damages worth more than $800 million.

What Alleged Fraud did Methodist Hospital Commit?

According to the federal government’s motion to intervene, Methodist knowingly paid kickbacks to West Clinic physicians for referring its cancer patients for hospital admissions, chemical infusions, radiation, and outpatient procedures to Methodist. The original lawsuits claimed that West physicians received more than $400 million in kickbacks between 2012 and 2018.

As part of a multi-agreement transaction, West allegedly managed inpatient and outpatient cancer care at Methodist and brought patient referrals to Methodist instead of sending them to other clinics, which increased the hospital’s revenues. The lawsuit claims that Methodist received $1.5 billion of net profit over seven years.

The number of cancer patients admitted to Methodist between 2012 and 2014 increased twofold, from 7,320 to 15,834 in just two years. The lawsuit claims that Medicare payments to Methodist for outpatient services also grew from $40.14 million in 2011 to $84.65 million in 2014 and reached $123.65 million in 2017.

Overall, the Medicare payments to Methodist for outpatient services increased by 300%.

The lawsuit alleged that being a part of the 340B program, Methodist was able to purchase drugs at a discount at the same time charging the patients’ insurance at a higher rate. The difference would be split between West and Methodist.

Why is the Federal Government’s Motion to Join Important for the Methodist Hospital Whistleblowing Case?

The government’s decision to intervene makes a big difference in fighting fraud and protecting patients because medical decisions premised on kickbacks pose a threat to everybody.

If you have become aware of a fraud or abuse scheme, you may be able to act as a whistleblower. The national whistleblower attorney, Arvind Bob Khurana, helps individuals build a strong case and potentially claim a whistleblower reward for aiding the government. Contact us today for a consultation. For a free, confidential evaluation call (888) 335-5107

source https://medicarewhistleblowercenter.com/federal-government-asks-to-join-800-million-whistleblower-lawsuit-against-methodist-hospital/

Five Former Celtics Players Charged in $ 4 Million Health Care Fraud

Five former players of the Boston Celtics were listed among nearly two dozen ex-NBA players arrested and charged on October 7 after an alleged multi-million-dollar health insurance fraud scheme.

Manhattan federal prosecutors indicted Terrence Williams, Glen Davis, Tony Allen, Milt Palacio, and Sebastian Telfair as well as 13 other ex-league players for allegedly engaging in a health insurance scheme.

Former National Basketball Association players allegedly defrauded the NBA Players’ Health and Welfare Benefit Plan of nearly $4 million by submitting fictitious reimbursement claims for medical and dental expenses.

The defendants face charges of conspiracy to commit health care fraud and wire fraud, as well as aggravated identity theft. The charges could lead to up to 20 years in prison.

How Did Ex-Players Defraud The Supplemental Coverage Plan?

According to an indictment, the alleged conspiracy leader was Terrence Williams, who later recruited other ex-NBA players to defraud the plan funded mostly by NBA teams. He also offered to provide fake invoices for medical and dental procedures to the players in exchange for kickback payments.

The defendants allegedly carried out the scheme from at least 2017 up to around 2020. Over the three-year period, the false claims reached about $3.9 million, from which the ex-players allegedly got about $2.5 million reimbursed in fraudulent proceeds each player making from $65,000 to $420,000.

Attorney for the Southern District of New York Audrey Strauss told at a press conference that prosecutors had enough data proving that many times the defendants were far from the medical offices, sometimes even abroad, when they were supposedly getting the treatment.

Why Is The Ex-Nba Health Care Fraud Case Important?

The former NBA players’ alleged health insurance fraud scheme came just a few weeks after former NFL players Clinton Portis, Tamarick Vanover, and Robert McCune pleaded guilty to a nationwide health care fraud scheme.

U.S. Department of Justice announced on September 8 that all three ex-NFL players admitted engaging in defrauding Gene Upshaw NFL Player Health Reimbursement Account Plan (“HRA Plan”) instituted to reimburse medical expenses for retired players and their families.

Both recent cases are just the two examples showing the prosecutor’s commitment to combating health care fraud. The head of New York’s FBI office Michael J. Driscoll said the ex-NBA alleged health insurance fraud case demonstrated the FBI’s continued focus on uncovering fraud scams that cost the healthcare industry tens of billions of dollars a year.

What Do Whistleblower Lawyers Say About Health Care Fraud Scams?

Whistleblower lawyers believe fraud poses a major challenge to the United States health care system. U.S. Department of Justice reported a $2.6 billion-dollar loss attributed to healthcare fraud and abuse in the fiscal year 2019 alone.

If you have become aware of a fraud or abuse scheme, you may be able to act as a whistleblower. The whistleblower attorney Arvind Bob Khurana helps people to build a strong case that will help them receive a reward for aiding the government to fight against fraud. Contact us today for a consultation. For a free, confidential evaluation call (888) 335-5107

source https://medicarewhistleblowercenter.com/five-former-celtics-players-charged-in-4-million-health-care-fraud/

Sutter Health to Pay $90 Million in Largest Medicare Advantage Fraud Settlement

One of the largest US health care providers, Sutter Health, has agreed to pay $90 million to settle allegations of violating the False Claims Act (FCA) resolving the 2015 whistleblower suit. California-based hospital operator was accused of knowingly submitting inaccurate information about their patients’ health status enrolled in Sutter Health’s contracted Medicare Advantage Plans stated the U.S. Department of Justice.

The settlement, which is believed to be the largest FCA case against a hospital system over Medicare Advantage, was made on August 30, 2021, and once again underlined the benefits of whistleblowing in the healthcare sector.

What Alleged Fraud did Sutter Health Commit?

The whistleblower lawsuit was originally filed in 2015 by a former employee of Sutter Health. The case alleged that starting from 2010 Sutter Health and its medical practice foundation affiliates knowingly submitted unsupported diagnosis codes to its contracted Medicare Advantage Plans to increase its reimbursement for provided services.

Sutter Health’s contracted Medicare Advantage Plans received larger payments by making patients appear sicker than they actually were. Once aware of the unsupported codes, the healthcare service provider failed to take sufficient action which led to the system abuse.

Why is the Sutter Health Whistleblowing Case Important for the Medicare Program?

Whistleblowing is an essential tool for the government in going after misconduct and therefore protecting the public, especially when it comes to the Medicare program. Sutter Health’s case sets an important example of whistleblowers teaming up with lawyers and government officials to fight against fraud in the healthcare sector.

The “result sends a clear message that we will hold healthcare providers responsible if they knowingly provide or fail to correct information that is untruthful,” said the Justice Department’s Civil Division’s Deputy Assistant Attorney General Sarah Harrington.

In announcing the settlement, the Department of Justice representatives underlined their ongoing efforts to fight fraud within the Medicare Advantage program. In addition to the payment, Sutter Health signed a five-year corporate integrity agreement, which calls for a centralized risk assessment program. Under such a program the healthcare provider has to hire an outside organization to review its patient diagnostic data each year.

What Compensation does Sutter Health Case Whistleblower Get?

Often, the whistleblower is expected to receive 15% to 25% of the recovered funds if the government joins the case, or 25% to 30% of recovery if the government decides not to take on the case.

In the Sutter Health case, according to the media reports, the whistleblower is expected to get 15% to 30% of the settlement under the FCA, while the exact share is yet to be determined.

At Khurana Law Firm, P.C., experienced Medicare whistleblower lawyers support the decision to come forward to report abuse and fraud in the Medicare Advantage program.

Contact us today for a free, confidential consultation at (888) 335-5107

source https://medicarewhistleblowercenter.com/sutter-health-to-pay-90-million-in-largest-medicare-advantage-fraud-settlement/