Pasadena doctor who falsely claimed patients were terminally ill is sentenced to four years for fraud

http://www.latimes.com/local/lanow/la-me-ln-pasadena-doctor-prison-20160824-snap-story.html?utm_campaign=CHL%3A+Daily+Edition&utm_source=hs_email&utm_medium=email&utm_content=33409508&_hsenc=p2ANqtz–KDKuU4PH1yztKbkXarPsY58B6-80M433Uz-u6qd86BDE6zJ4zbv5sPgwskL5rfPSDgOeUJw0jeuHlEK79jrfz4jh2Jg&_hsmi=33409508

Image result for false claims for hospiceImage result for false claims for hospice

A Pasadena doctor convicted of falsely certifying that more than 79 patients were terminally ill as part of a scheme to bilk Medicare and Medi-Cal was sentenced by a federal judge to four years in prison.

U.S. District Judge S. James Otero also ordered Boyao Huang, 43, to pay $1,344,204 in restitution last week. In May, Huang was found guilty of four counts of healthcare fraud at the conclusion of a two-week trial that centered on a ploy to defraud the government of $8.8 million by making it pay for hospice-related services. Huang could have received up to 10 years in prison for each of the counts.

Florida scam reveals breadth of compound pharmaceutical billing

http://www.fiercehealthcare.com/antifraud/florida-scam-reveals-breadth-compound-pharmaceutical-billing?mkt_tok=eyJpIjoiTTJNNE9ESmpNR1psWmpWaSIsInQiOiJXOXlcL0xySWFOazE4RUJ3cUNVaWtoMnZ3WVZDMUdQUGlLUmNaemNHZklCMEhJQW1xS01MNE1pRGNXUlpURXBUVGtDOE5nQWxqUmRMZ3BOSGZwT1pDajV4dHRma0hQZ1F4amlFNnBEZGhqdW89In0%3D&mrkid=959610&utm_medium=nl&utm_source=internal

DrugsDrugs

Eight Florida residents were charged last week with billing the federal government more than $633 million for compounded pharmaceuticals over a three-year period, according to the U.S. Attorney’s Office for the Middle District of Florida–events that underscore the intensity of emerging fraud concerns about compounded drugs.

A group of eight co-conspirators, led by Nicholas A. Borgesano—the president of five pharmacies and several medical billing companies in Tampa Bay and Miami—billed Medicare, Tricare and private insurance companies more than $633 million for compounded pharmaceutical prescriptions between October 2012 and December 2015, according to the indictment.

The group was paid more than $157 million for illegitimate prescriptions that were often allegedly the result of elaborate kickbacks. In some instances, the group allegedly misrepresented some claims by billing for certain high-priced ingredients that were not included in the final compounded prescription.

As part of the arrest, authorities confiscated 17 properties, 15 luxury vehicles and several boats.

Earlier this year, federal and state authorities raided pharmacies in four states, including Florida, as part of a widespread bust involving compounding pharmacies. Federal officials have been targeting compounding pharmacies following a spike in high-priced Tricare claims. Investigators and legal experts have said the cases and investigations brought forward thus far are “just the beginning.”

Appeals court reopens whistleblower’s case against Medicare Advantage orgs

http://www.fiercehealthcare.com/payer/appeals-court-reopens-whistleblower-s-case-against-medicare-advantage-orgs?utm_medium=nl&utm_source=internal&mrkid=959610&mkt_tok=eyJpIjoiTTJNNE9ESmpNR1psWmpWaSIsInQiOiJXOXlcL0xySWFOazE4RUJ3cUNVaWtoMnZ3WVZDMUdQUGlLUmNaemNHZklCMEhJQW1xS01MNE1pRGNXUlpURXBUVGtDOE5nQWxqUmRMZ3BOSGZwT1pDajV4dHRma0hQZ1F4amlFNnBEZGhqdW89In0%3D

In a newly issued opinion, a federal appeals court gives a whistleblower another chance to make his case that major health insurers inflated Medicare Advantage risk scores to collect greater government payments.

The Centers for Medicare & Medicaid Services pays Medicare Advantage organizations based on a risk score calculated by measuring a beneficiary’s overall health, with higher payments for sicker patients.

But whistleblower James Swoben claims that UnitedHealth, Aetna, WellPoint, Health Net and physician group HealthCare Partners gamed the system by conducting biased retrospective reviews of medical records already submitted to CMS. Such reviews would violate the False Claims Act.

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

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.

26 latest healthcare industry lawsuits, settlements

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

 

Houston physician gets 3-year prison term for fraud

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

Fraud

Healthcare CEO faces life in prison for fraud that led to 2 patient deaths

http://www.beckershospitalreview.com/legal-regulatory-issues/healthcare-ceo-faces-life-in-prison-for-fraud-that-led-to-2-patient-deaths.html

Fraud

The CEO and co-owner of a Maryland diagnostics company is facing life in prison after a federal jury convicted him of two counts of healthcare fraud that resulted in death, according to the Department of Justice.

On Wednesday, a federal jury found 67-year-old Rafael Chikvashvili, PhD, guilty of healthcare fraud. Dr. Chikvashvili was the co-owner and CEO of Owings Mills, Md.-based Alpha Diagnostics, which was a portable diagnostic services provider, principally of X-rays.

According to evidence presented at trial, Dr. Chikvashvili was involved in a scheme to defraud Medicare and Medicaid. He and others allegedly conspired to create false radiology, ultrasound and cardiologic interpretation reports. He also allegedly submitted insurance claims for medical examination interpretations that were never completed by licensed physicians, according to the DOJ.

Dr. Chikvashvili allegedly instructed his nonphysician employees to interpret X-rays, ultrasounds and cardiologic examinations, which, according to testimony provided at trial, resulted in two patient deaths.

Justice Department joins lawsuit against Prime Healthcare

http://www.healthcaredive.com/news/justice-department-joins-lawsuit-against-prime-healthcare/419849/

Judges Gavel

The U.S. Justice Department recently filed notice in U.S. District Court in Los Angeles that it is partly intervening in a whistle-blower case against Prime Healthcare Services. The whistle-blower lawsuit alleges that Prime Healthcare fraudulently billed Medicare for beneficiaries admitted as inpatients instead of treating them as outpatients.

http://www.healthcaredive.com/news/doj-accuses-prime-of-driving-up-medicare-admissions/421800/

Supreme Court upholds implied certification theory under the FCA

http://www.healthcaredive.com/news/supreme-court-upholds-implied-certification-theory-under-the-fca/421383/

Supreme Court6

In its decision, the Court addressed two major issues. Of greatest significance, it approved an “implied false certification theory of liability” in FCA cases. “The law now treats a provider’s payment request as an implied certification of compliance with all relevant statutes, regulations, or contract requirements, says Brian Mahany, a healthcare fraud expert and whistleblower claims lawyer.

What’s more significant is that for the first time, the Supreme Court imposed real limitations on implied certification. Based on the Court’s decision, for a claim to be considered false or fraudulent under the implied certification theory,” the regulation or contractual provision impliedly violated be must be “material” to the government’s payment decision. “In so holding, the court plainly rejected the government’s more expansive reading of the law,” says Kalb.

Supreme Court issues key decision on False Claims Act liability: 9 things to know

http://www.beckershospitalreview.com/legal-regulatory-issues/supreme-court-issues-key-decision-on-false-claims-act-liability-9-things-to-know.html

Supreme Court

Commenting on the Supreme Court’s decision, Jessica L. Ellsworth, partner at Hogan Lovells, says the limitations demonstrated that the high court “fully understood that the False Claims Act remains about fraudulent conduct — not garden variety foot-faults that a regulated party may experience in complying with complex regulatory and statutory obligations.”