Tag Archives: DOJ

Fake owner pleads guilty in $4.2M home health fraud scheme

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http://www.healthcaredive.com/news/fake-owner-pleads-guilty-in-42m-home-health-fraud-scheme/424577/

  • Ramon Collado Gonzalez of Miami, Florida pleaded guilty Monday to acting as the straw owner of Golden Home Health Care as part of a $4.2 million home healthcare fraud scheme, the U.S. Attorney’s Office for the Southern District of Florida announced Tuesday.
  • Gonzalez admitted he was recruited to cover for the real owners, Mildrey Gonzalez and Milka Alfaro, who were charged separately for their alleged roles.
  • Gonzalez signed documents for the submission of false Medicare claims in exchange for monthly payments and periodic bonuses, the press release states.

Battle of the bulls: Aetna threatened ACA participation over Humana merger blockage

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http://www.healthcaredive.com/news/battle-of-the-bulls-aetna-threatened-aca-participation-over-humana-merger/424640/

  • In July, Aetna sent a letter to the Justice Department insinuating it would leave the ACA market if its pending merger with Humana was blocked by the DOJ, The Huffington Post reported.
  • Aetna announced late Monday it was exiting nearly 70% of the ACA markets it participated in next year (parsing down 778 counties to 242).
  • On Monday, CEO Mark Bertolini cited losses in the millions as the reason for the decision. However, the July letter obtained by The Huffington Post implies the decision was more influenced by the Justice Department lawsuit.

26 latest healthcare industry lawsuits, settlements

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http://www.beckershospitalreview.com/legal-regulatory-issues/26-latest-healthcare-industry-lawsuits-settlements-august15.html

 

In Battle Of Health Care Titans, Should Insurers Act Like Wal-Mart?

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http://www.npr.org/sections/health-shots/2016/08/11/488891554/should-big-insurance-become-like-walmart-to-lower-health-costs

Who has the upper hand in health care prices?

In late July, the Justice Department sued to block both insurance mergers, arguing that competition is important to keep premiums down and that the deals “would leave much of the multitrillion-dollar health insurance industry in the hands of three mammoth insurance companies.”

They also rejected the Wal-Mart argument, which is related to what economists call “monopsony,” a concentration of buying power.

Monopsony is the opposite of monopoly: Instead of using market dominance to raise prices for consumers, huge buyers force down prices from suppliers. Wal-Mart is often described as holding monopsony-like power.

But critics of the insurance deals say monopsony can go too far. If the buyer pushes prices too low, suppliers stop producing, making needed goods and services unavailable.

“As a result of the merger, Anthem likely would reduce the rates that … providers earn by providing medical care to their patients,” the Justice Department argued. “This reduction in reimbursement rates likely would lead to a reduction in consumers’ access to medical care.”

Tenet Healthcare agrees to plead guilty in Atlanta kickback scheme, will pay $514 million

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http://www.bizjournals.com/atlanta/news/2016/08/01/tenet-healthcare-agrees-to-plead-guilty-in-atlanta.html

Atlanta Medical Center, previously one of Tenet Healthcare’s Georgia hospitals, was involved in the scheme.

Tenet Healthcare Corp. (NYSE: THC) said Monday that it believes it has reached an agreement in principle with the government to resolve a long-running criminal investigation and civil litigation about a kick-back scandal involving an Atlanta medical clinic and three of the company’s Atlanta-area hospitals.

Dallas-based Tenet said it has agreed to pay $514 million, has agreed to the appointment by the U.S. Department of Justice of a corporate monitor for a period of three years, and has agreed for two wholly owned subsidiaries that previously operated Atlanta Medical Center and North Fulton Hospital to each plead guilty to a single-count indictment. The settlement will be with the U.S. Department of Justice, the U.S. Attorneys’ Offices for the Northern and Middle Districts of Georgia, and the Georgia Attorney General’s Office.

Atlanta Medical Center, previously one of Tenet Healthcare’s Georgia hospitals, was involved in the scheme.

Tenet Healthcare Corp. (NYSE: THC) said Monday that it believes it has reached an agreement in principle with the government to resolve a long-running criminal investigation and civil litigation about a kick-back scandal involving an Atlanta medical clinic and three of the company’s Atlanta-area hospitals.

Dallas-based Tenet said it has agreed to pay $514 million, has agreed to the appointment by the U.S. Department of Justice of a corporate monitor for a period of three years, and has agreed for two wholly owned subsidiaries that previously operated Atlanta Medical Center and North Fulton Hospital to each plead guilty to a single-count indictment. The settlement will be with the U.S. Department of Justice, the U.S. Attorneys’ Offices for the Northern and Middle Districts of Georgia, and the Georgia Attorney General’s Office.

“The agreement in principle contemplates, among other things, payment by the company of $513,788,345, which is comprised of a civil monetary payment of $368,000,000 and a criminal monetary payment of $145,788,345,” Tenet reported Monday.

The company’s two subsidiaries will plead guilty to a single count of conspiracy to violate the federal anti-kickback statute and defraud the United States, Tenet reported.

Hospital Chain’s CEO Faces Lawsuit Over Business Practices

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http://www.wsj.com/articles/hospital-chains-ceo-faces-lawsuit-over-business-practices-1470021573

Prem Reddy, head of Prime Healthcare, is known for his aggressive turnaround strategies.

Anthem’s Good, Bad and Ugly News

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http://www.bloomberg.com/gadfly/articles/2016-07-27/anthem-earnings-the-good-the-bad-and-the-ugly?_hsenc=p2ANqtz-9r6DeQcVMyNnafhqaWRYPxsGcyFkKJ80w17xLndiqVNIIOrCFlnm-c4sSm8WS6EqhbFxAmVmQuwhj1GdEe1f5nt4irUw&_hsmi=32205122&utm_campaign=KHN%3A+Daily+Health+Policy+Report&utm_content=32205122&utm_medium=email&utm_source=hs_email

Anthem had some good headlines on Wednesday. The insurer reported second-quarter earnings and revenue that topped estimates, with the latter jumping 7.2 percent from a year earlier. It expects to insure more people than it initially forecast this year, after surprisingly robust growth in its Medicaid business.

But beneath the good, there was also bad and ugly.

Standard & Poor’s puts Aetna, Humana on credit watch following DOJ move to block merger

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http://www.healthcarefinancenews.com/news/standard-poors-puts-aetna-humana-credit-watch-following-doj-move-block-merger

S&P Global Ratings has placed Aetna and Humana on creditwatch following the Department of Justice’s announcement Thursday to block their merger.

S&P said it has placed its ratings on Aetna on creditwatch with developing implications, and on Humana and its core subsidiaries on creditwatch with negative implications.

The DOJ also blocked the merger between Anthem and Cigna on Thursday.  S&Psaid its ratings on the two insurers would remain on creditwatch negative, where they were placed on June 21, 2015.

Anthem and Aetna have both said they would fight the DOJ’s injunction against their respective mergers in court.

For Anthem’s proposed $53 billion acquisition of Cigna, litigation could be difficult and time-consuming, S&P said.

3 charged in $1 billion scheme to defraud Medicare in Florida, DOJ dubs biggest ever

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http://www.healthcarefinancenews.com/news/3-charged-1-billion-scheme-defraud-medicare-florida-doj-dubs-biggest-ever

The owner of more than 30 Miami-area skilled nursing and assisted living facilities, a hospital administrator and a physician’s assistant were charged with conspiracy, obstruction, money laundering and healthcare fraud in connection with a $1 billion scheme involving numerous Miami-based providers, the United States Department of Justice announced.

Assistant Attorney General Leslie Caldwell of the Justice Department’s Criminal Division said in a statement that the charges represent the largest single criminal healthcare fraud case ever brought against individuals by the DOJ.

Philip Esformes, 47, Odette Barcha, 49, and Arnaldo Carmouze, 56, all of Miami-Dade County, Florida, were charged in an indictment claiming that Esformes operated a network of more than 30 skilled nursing homes and assisted living facilities known as The Esformes Network, which gave him access to thousands of Medicare and Medicaid beneficiaries.

Houston physician gets 3-year prison term for fraud

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http://www.beckershospitalreview.com/legal-regulatory-issues/houston-physician-gets-3-year-prison-term-for-fraud.html

Fraud