CVS long-term care pharmacy sued by DOJ over fraudulent prescribing practices

https://www.healthcaredive.com/news/cvs-long-term-pharmacy-sued-by-doj-over-fraudulent-prescribing-practices/569268/

Dive Brief:

  • CVS Health and its Omnicare business are being sued by the Department of Justice over alleged fraudulent billing of Medicare and other government programs for outdated prescriptions for elderly and disabled people.
  • The DOJ suit, filed Tuesday in New York, joins whistleblower ligitation accusing Omnicare of billing federal healthcare programs for hundreds of thousands of drugs based on out-of-date prescriptions for individuals in assisted living facilities, group homes, independent living communities and other long-term care facilities between 2010 and 2018. The lawsuit seeks civil penalties and other damages.
  • “We do not believe there is merit to these claims and we intend to vigorously defend the matter in court,” CVS spokesperson Joe Goode told Healthcare Dive. “We are confident that Omnicare’s dispensing practices will be found to be consistent with state requirements and industry-accepted practices.”

Dive Insight:

The suit alleges Omnicare, the nation’s largest long-term care pharmacy, kept dispensing antipsychotics, anticonvulsants, antidepressants and other drugs based off invalid prescriptions for months, and sometimes years, without obtaining fresh scripts from patients’ doctors.

Managers at the long-term care business allegedly ignored prescription refill limitations and expiration dates and forced staff to fill prescriptions quickly, pressuring some facilities to process and dispense thousands of orders daily. When prescriptions expired, Omnicare “rolled over” the scripts, assigning them a new number, allowing the pharmacy to dispense the drug indefinitely without need for doctor involvement.

This practice allowed Omnicare to continually dispenses drugs for seniors and disabled occupants in more than 3,000 residential long-term care facilities, at an ongoing risk to their health, according to DOJ. Many of the prescription drugs were meant to treat serious conditions like dementia, depression or heart disease and have side effects when not closely monitored by a physician — particularly when taken in tandem with other medications.

The pharmacy then submitted knowingly false claims to Medicare, Medicaid and TRICARE, which serves military personnel, for the illegally dispensed drugs over an eight-year period; and lied to the government about the status of the prescriptions. CVS Health senior management was also aware of the scheme, according to DOJ.

“A pharmacy’s fundamental obligation is to ensure that drugs are dispensed only under the supervision of treating doctors who monitor patients’ drug therapies,” Manhattan U.S. Attorney Geoffrey Berman said in a statement. “Omnicare blatantly ignored this obligation in favor drugs out the door as quickly as possible to make more money.”

The government joined the lawsuit originally brought by Uri Bassan, an Albuquerque, New Mexico pharmacist for Omnicare, filed in June 2015. The original whistleblower suit said Omnicare’s compliance department was aware of the “rolling over” process, but did nothing to stop it.

This is by no means the first time the CVS subsidiary, established in 1981 and acquired in 2015 for about $12.7 billion, has been under the federal microscope for fraud.

Omnicare has a history of friction with the DOJ
  • 2006Omnicare pays almost $50 million over improper Medicaid claims

  • 2009Omnicare shells out $98 million to settle kickback allegations

  • 2012Omnicare enters into a $50 million settlement following a DOJ investigation finding its pharmacies dispensed drugs to long-term care facility residents without valid prescriptions

  • Feb. 2014Omnicare pays the government more than $4 million to settle kickback allegations

In the May 16, 2017 suit, the government accused Omnicare of designing an automated label verification system that purposefully inflated profits by submitting claims for generic drugs different than those given to patients. CVS said that all happened before it acquired Omnicare.

​Omnicare provides pharmacy benefits for post-acute care and senior living care, including in skilled nursing facilities, hospitals and health systems and assisted living communities.

Despite the lucrative market in an aging U.S. population with complicated drug needs, Omnicare is an underperforming business in otherwise healthy times for CVS. The unit triggered a $2.2 billion goodwill impairment charge following a late 2018 test, according to CVS’ fourth quarter filing last year.

Omnicare operates 160 pharmacies in 47 states. During the eight years under investigation, Omnicare submitted more than 35 million claims for drugs dispensed to Medicare beneficiaries in assisted living facilities alone, DOJ says.

 

 

 

 

California surgeon gets prison time for role in $580M billing fraud scheme

https://www.beckershospitalreview.com/legal-regulatory-issues/california-surgeon-gets-prison-time-for-role-in-580m-billing-fraud-scheme.html?origin=cfoe&utm_source=cfoe

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An orthopedic surgeon was sentenced to 30 months in federal prison Nov. 22 for his role in a healthcare fraud scheme that resulted in the submission of more than $580 million in fraudulent claims, mostly to California’s worker compensation system, according to the Department of Justice.

Daniel Capen, MD, was sentenced more than a year after pleading guilty to conspiracy to commit honest services fraud and soliciting and receiving kickbacks for healthcare referrals. He was one of 17 defendants charged in relation to the government’s investigation into kickbacks physicians received for patient referrals for spinal surgeries performed at Pacific Hospital in Long Beach, Calif.

Dr. Capen received at least $5 million in kickbacks for referring surgeries to Pacific Hospital and for referring services to organizations affiliated with the hospital. He allegedly accounted for $142 million of Pacific Hospital’s claims to insurers between 1998 and 2013, according to the Justice Department.

In addition to the prison term, Dr. Capen was ordered to forfeit $5 million to the federal government and pay a $500,000 fine.

 

 

 

 

Adventist, St. Joseph merger rejected by California regulators

https://www.beckershospitalreview.com/hospital-transactions-and-valuation/adventist-st-joseph-merger-rejected-by-california-regulators.html

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The California Department of Justice denied a proposed merger between nonprofits Adventist Health System/West and St. Joseph Health System Oct. 31, stating it’s not in the public’s interest.

The transaction would increase healthcare costs and possibly limit healthcare access in Northern California, the department determined.

In June 2018, Roseville, Calif.-based Adventist and Irvine, Calif.-based St. Joseph requested to form a joint operating company to integrate 10 select facilities in Northern California. At the time, the systems said their integration would improve healthcare access, especially for vulnerable and underserved patients. 

Sean McCluskie, chief deputy to California’s attorney general, disagreed with those predictions.

“The California Department of Justice is responsible for ensuring that any proposed sale or transfer of a nonprofit health facility protects the health and safety interests of the surrounding community. After careful review, we found this proposal falls short of protecting consumers,” he said.

In a joint statement to Becker’s, Adventist and St. Joseph expressed disappointment about the department’s decision.

“Our intent has always been to better serve our communities, increase access to services, and create a stronger safety net for families in Northern California,” they said. “At this time, our organizations will need to take a step back and determine implications of this decision. The well-being of our communities remains our top priority.”

 

DOJ breaks up alleged genetic testing fraud scheme estimated at $2.1 billion

https://www.healthcarefinancenews.com/news/doj-breaks-alleged-genetic-testing-fraud-scheme-estimated-21-billion?mkt_tok=eyJpIjoiWkdNMU56WmxabVl3TWpRMSIsInQiOiI0dlhaYUJpT2xBU0FqeDNmWkRlZHVZYnRsZ2xBK3pxMmN6RG5kS3Q1UWgrWFYyNllIK2lLZEYzclRDWUYyTFwvOGdhUzRVSnlscG5MQjBtY0NwT2d1TjZHdXJYRUlYRGszVEhrQmY5b0xhRDlFTWNTNUEwWnVvWGUwZXE3ME9kdGgifQ%3D%3D

The defendants ordered unnecessary tests that were reimbursed by Medicare, with laboratories sharing the profit, DOJ says.

The U.S. Department of Justice has charged 35 people with unlawfully charging Medicare $2.1 billion in what it said is one of the largest healthcare fraud schemes in history.

The 35 alleged offenders were charged in five separate federal districts, and were linked to dozens of telemedicine firms and laboratories focused on genetic testing for cancer. The people charged, including nine doctors and one other medical professional, cumulatively billed Medicare billions for cancer genetic tests, the DOJ said in a press release.

The charges were a culmination of coordinated law enforcement activities over the past month that were led by the Criminal Division’s Health Care Fraud Unit, resulting in charges against more than 380 individuals who allegedly billed federal healthcare programs for more than $3 billion, and allegedly prescribed and dispensed approximately 50 million controlled substance pills in Houston, across Texas, the West Coast, the Gulf Coast, the Northeast, Florida and Georgia, and the Midwest.

These include charges against 105 defendants for opioid-related offenses, and charges against 178 medical professionals.

The investigation targeted an alleged scheme involving the payment of illegal kickbacks and bribes by CGx laboratories in exchange for the referral of Medicare beneficiaries by medical professionals working with fraudulent telemedicine companies for expensive, and medically unnecessary, cancer genetic tests.

According to the DOJ, the targets of the scheme were primarily seniors, who were approached at health fairs, at their homes during door-to-door visits, or through telemarketing calls. The “recruiters,” as they were called, would approach seniors about supposedly free cancer screenings or generic cheek swab tests, and the recruiters would then obtain the seniors’ Medicare information for the purposes of fraudulent billing or identify theft.

The recruiter would then get a doctor to sign off on a genetic so a lab would process it, and then pay a kickback in exchange for ordering the test. The lab would process the test and bill Medicare, and once it was reimbursed, would share the proceeds with the recruiter, according to the charges.

Often, the test results were not provided to the beneficiaries, or were worthless to their actual doctors. Some of the defendants allegedly controlled a telemarketing network that lured hundreds of thousands of elderly and/or disabled patients into a criminal scheme that affected victims across the U.S.

The defendants allegedly paid doctors to prescribe CGx testing, either without any patient interaction or with only a brief phone conversation with patients they had never met or seen.

WHAT’S THE IMPACT

In addition to the DOJ charges, the Centers for Medicare and Medicaid Services, Center for Program Integrity said it took adverse administrative action against cancer genetic testing companies and medical professionals who submitted more than $1.7 billion in claims to the Medicare program.

The DOJ Criminal Division, along with the U.S. Department of Health and Human Services Office of Inspector General and the FBI, spearheaded the investigation.

The DOJ calls the scheme one of the largest it has ever handled.

THE LARGER TREND

Since its inception in March 2007, the Medicare Fraud Strike Force, which maintains 15 strike forces operating in 24 districts, has charged nearly 4,000 defendants who have collectively billed the Medicare program for more than $16 billion.

In addition, CMS, working in conjunction with the Health and Human Services Office of the Inspector General, are taking steps to increase accountability and decrease the presence of fraudulent providers.

The newest Medicare fraud scheme is the second to be uncovered in the last month. Earlier in September, a telemedicine CEO pleaded guilty to one count of conspiracy to defraud the United States and pay and receive healthcare kickbacks and one count of conspiracy to commit money laundering in a scheme estimated at $424 million.

ON THE RECORD

“Unfortunately, audacious schemes such as those alleged in the indictments are pervasive and exploit the promise of new medical technologies such as genetic testing and telemedicine for financial gain, not patient care,” said Deputy Inspector General for Investigations Gary L. Cantrell of HHS-OIG. “Instead of receiving quality care, Medicare beneficiaries may be victimized in the form of scare tactics, identity theft, and in some cases, left to pay out of pocket.  We will continue working with our law enforcement partners to investigate those who steal from federal healthcare programs and protect the millions of Americans who rely on them.”

“Healthcare fraud and related illegal kickbacks and bribes impact the entire nation,” said Assistant Director Terry Wade of the FBI’s Criminal Investigative Division. “Fraudulently using genetic testing laboratories for unnecessary tests erodes the confidence of patients and costs taxpayers millions of dollars. These investigations revealed some medical professionals placing their greed before the needs of the patients and communities they serve. Today’s law enforcement actions reinforce that the FBI, along with its partners, will continue to pursue and stop this type of illegal activity.”

 

Texas docs, pharmacists charged in alleged opioid pill mill scheme

https://www.healthcaredive.com/news/texas-docs-pharmacists-charged-in-alleged-opioid-pill-mill-scheme/563270/

Dive Brief:

  • The U.S. Department of Justice said Wednesday it charged 58 people in Texas in connection with their alleged roles in various schemes to defraud government health programs, including distributing and dispensing medically unnecessary opioids, billing Medicaid for non-emergency ambulance services that were never actually provided and paying kickbacks and laundering money through durable medical equipment companies.
  • The allegations involved multiple programs including Medicare, Medicaid, TRICARE, the Department of Labor-Office of Worker’s Compensation programs as well as private insurance companies.
  • Separately, DOJ brought charges against a total of 34 people for their alleged participation in Medicare and Medicaid fraud schemes in other states, including California, Arizona and Oregon. Seventeen of the people charged in those schemes were doctors or licensed medical professionals.

Dive Insight:

Created in 2007, the Medicare Fraud Strike Force​ has units operating in 23 districts, and has charged nearly 4,000 defendants who have collectively billed the Medicare program for more than $14 billion. It’s a joint effort between DOJ and HHS to deter healthcare fraud.

According to the most recent statistics, from January, the strike force has brought 2,117 criminal actions, secured 2,754 indictments and recovered $3.3 billion in connection with its investigations.

HHS declared the opioid crisis a national emergency in 2017. And the DOJ is increasingly focusing on fraud related to opioids, including going after medical professionals allegedly involved in the unlawful distribution of opioids and other prescription narcotics.

“Sadly, opioid proliferation is nothing new to Americans,” U.S. Attorney Ryan K. Patrick of the Southern District of Texas said in a statement announcing the charges. “What is new is the reinforced fight being taken to dirty doctors and shady pharmacists,” he said.

The coordinated healthcare fraud enforcement operation across Texas resulted in charges involving networks of “pill mill” clinics that led to $66 million in losses and the distribution of 6.2 million pills, the government said. Sixteen doctors and pharmacists were among those charged.

And that’s on top of last month, when the Health Care Fraud Unit’s Houston Strike Force charged dozens of people in a trafficking network that diverted more than 23 million oxycodone, hydrocodone and carisoprodol pills.

The Texas actions also involved healthcare fraud other than opioid diversion, including fraudulent physician orders for durable medical equipment, fraudulent claims for ambulance services and stealing protected healthcare information.

The separate actions in California, Arizona and Oregon involved schemes that ran the gamut from billing for medically unnecessary compounded drugs, unnecessary cardiac treatments and testing, billing for chiropractic services never provided and a hospice kickback scheme.

 

 

 

Telemedicine CEO pleads guilty in $424 million Medicare fraud scheme

https://www.modernhealthcare.com/legal/telemedicine-ceo-pleads-guilty-424-million-medicare-fraud-scheme?utm_source=modern-healthcare-daily-finance&utm_medium=email&utm_campaign=20190909&utm_content=article1-readmore

The owner of telemedicine company Video Doctor Network on Friday pleaded guilty for his role in what the Justice Department is calling one of the largest healthcare fraud schemes prosecuted to date in the U.S.

Lester Stockett, 52, a resident of Colombia, agreed to pay $200 million in restitution to the U.S. as part of his plea agreement.

The Justice Department in April brought charges against 24 defendants including Stockett for their role in a $424 million conspiracy to defraud Medicare and receive illegal kickbacks. Stockett’s company allegedly received kickbacks from brace suppliers in exchange for arranging for physicians to order medically unnecessary medical equipment, such as back, knee and shoulder braces.

Stockett, owner of the Video Doctor Network and CEO of one of its subsidiaries, AffordADoc, on Friday pleaded guilty to one count of conspiracy to defraud the U.S. and pay and receive healthcare kickbacks, as well as one count of conspiracy to commit money laundering. His sentencing is set for Dec. 16 in New Jersey.

As part of his guilty plea, Stockett said he and others had solicited and received illegal kickbacks and bribes from patient recruiters, pharmacies and brace suppliers. In exchange, he said he and other Video Doctor Network employees bribed healthcare providers to order medically unnecessary orthotic braces for Medicare beneficiaries.

These Medicare beneficiaries were contacted through an international telemarketing network, which identified hundreds of thousands of elderly and disabled patients.

“This CEO and his co-conspirators lined their own pockets with hundreds of millions of dollars by exploiting telemedicine technology meant to help elderly and disabled patients in need of healthcare,” Assistant Attorney General Brian A. Benczkowski of the Justice Department’s Criminal Division said in a statement.

Brace suppliers, which were co-conspirators in the scheme, submitted more than $424 million in false and fraudulent claims to Medicare for these orders, Stockett said.

Medicare paid brace suppliers more than $200 million for these claims, according to the Justice Department.

Stockett said he and others hid illegal kickbacks and bribes by having them paid indirectly through nominee companies and bank accounts, both in the U.S. and in other countries.

Between March 2016 and April 2019, Stockett said he and other Video Doctor Network executives transferred more than $10 million in illegal kickback payments to a bank account in the Dominican Republic. They then transferred more than $9.8 million from that bank account in the Dominican Republic to bank accounts of AffordADoc in the U.S.

Stockett and other Video Doctor Network executives had also defrauded investors by claiming the company was a legitimate telemedicine enterprise that made $10 million in revenue annually, while revenue was obtained through illegal kickbacks and bribes, according to the plea agreement.

 

 

 

 

DOJ investigates Providence St. Joseph Health’s Swedish Health Services

https://www.modernhealthcare.com/providers/doj-investigates-providence-st-joseph-healths-swedish-health-services?utm_source=modern-healthcare-daily-finance-thursday&utm_medium=email&utm_campaign=20190829&utm_content=article1-readmore

The U.S. Department of Justice is probing Providence St. Joseph Health’s Swedish Health Services in a civil investigation, the not-for-profit integrated health system revealed in its recent quarterly earnings report.

The DOJ requested documents from Seattle-based Swedish related to certain arrangements, joint ventures and physician organizations, according to the report. Providence St. Joseph said that the investigation will not have a “material adverse effect” on its financials.

“Like all large institutions, Swedish is subject periodically to investigations and lawsuits,” Swedish said in a statement. “Per our policy, we are not able to discuss the specifics of any investigation. However, Swedish fully cooperates with all investigations.”

Renton, Wash.-based Providence St. Joseph also disclosed in the earnings report malpractice allegations against certain affiliates, although the “probable recoveries in these proceedings and the estimated costs and expenses of defense will be within applicable insurance limits or will not materially adversely affect the business or properties of the system,” the organization said.

The DOJ said in a statement that it does not confirm, deny or comment on investigations.

In 2014, HHS’ Office of Inspector General audited Swedish Health’s Swedish Medical Center–First Hill, an acute-care hospital in Seattle. It found that about two-thirds of 257 inpatient and outpatient claims from 2010 to 2012 did not fully comply with Medicare billing requirements, resulting in net overpayments of nearly $937,500.

Also, Swedish Health was accused in 2017 of asking neurosurgeons to increase patient volume and perform unnecessary surgeries.

The recent investigation involving Swedish may relate to a delicate balance providers must strike with their affiliates.

Health systems have been carefully navigating around the Stark law, which aims to curb Medicare and Medicaid spending by prohibiting physicians and hospitals from making referrals based on their financial self-interest. But the 1989 statutes conflict with outcome-oriented care, providers argue as the law dissuades them from incentive-based arrangements.

The Stark law offers little, if any, room for error and carries significant financial penalties, experts said. Maintaining compliance and abiding audits can drain resources.

Through six months of Providence St. Joseph Health’s 2019 fiscal year, it reported an operating income of $250 million on operating revenue of $12.6 billion, up from $30 million of operating income on $12 billion of operating revenue over the same period prior. The health system reported $41 million in restructuring costs, as it aims to streamline operations and boost productivity.

For 2018, the organization drew just $3 million in operating income last year on $24.4 billion in total operating revenue. Excluding asset impairment, severance and consulting costs related to restructuring, the system said its 2018 operating income would have been $165 million. The restructuring costs are being spread across 2018 and 2019.

As it restructures, Providence St. Joseph has been expanding its non-acute portfolio, forming a for-profit population health management company, launching its second, $150 million venture fund and buying a revenue-cycle management company based on blockchain technology.