EHR vendor, executives to pay $155M for allegedly misrepresenting software’s capabilities

http://www.beckershospitalreview.com/legal-regulatory-issues/ehr-vendor-executives-to-pay-155m-for-allegedly-misrepresenting-software-s-capabilities.html

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Westborough, Mass.-based eClinicalWorks, an EHR vendor, and some of its executives and employees have agreed to pay $155 million to resolve allegations it violated the False Claims Act, according to the Department of Justice.

HHS offers incentive payments to healthcare provider organizations that demonstrate meaningful use of certified EHR technology. Companies that develop and market EHR software must attest that their software meets certain criteria adopted by HHS and also pass testing by an HHS-approved entity.

The government alleged eClinicalWorks falsely obtained certification for its EHR software by withholding information from its certifying entity. For example, the company allegedly concealed that its software wasn’t able to meet certain criteria for standardized drug codes. Software must be able to retrieve any drug code from a complete database for certification. Instead of disclosing that its software didn’t meet this requirement, eClinicalWorks allegedly hardcoded only the 16 drug codes required for testing directly into its software.

Due to eClinicalWorks’ alleged misrepresentations, healthcare organizations using the company’s software submitted false claims for federal incentive payments, according to the DOJ.

The government also alleged the company paid kickbacks to certain customers in exchange for promoting its product.

Under the settlement agreement, eClinicalWorks and three of its founders — CEO Girish Navani, CMO Rajesh Dharampuriya, MD, and COO Mahesh Navani — will pay $154.92 million to the federal government. A software developer will pay an additional $50,000 and two project managers will each pay $15,000, according to the DOJ.

In addition to the monetary settlement, eClinicalWorks entered into a corporate integrity agreement with HHS’ Office of Inspector General that covers the company’s EHR software.

The allegations against eClinicalWorks were originally brought under the qui tam, or whistle-blower, provisions of the False Claims Act.

DOJ sues UnitedHealth over $1B+ in Medicare claims

http://www.beckershospitalreview.com/payer-issues/doj-sues-unitedhealth-over-1-billion-in-medicare-false-claims-again.html

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The Justice Department sued Minnetonka, Minn.-based UnitedHealth Group Tuesday, alleging the payer defrauded Medicare at least $1 billion in false claims.

In the 103-page lawsuit filed in a Los Angeles federal court, the Justice Department alleged the payer knowingly inflated risk adjustment payments by providing the government inaccurate data about the health status of its beneficiaries. Department officials cited UnitedHealth’s “one-sided” chart review process that reportedly didn’t address errors elevating its revenues.

The department also alleges the payer ignored “invalid diagnoses from healthcare providers with financial incentives to furnish such diagnoses.

The move follows the department’s decision to intervene in a whistle-blower suit filed by James Swoben in 2009. That suit alleges UnitedHealth billed Medicare higher payments for patients by “making patients look sicker than they” were. In an earlier statement to Star Tribune, UnitedHealth spokesperson Matt Burns said the payer denied the claims and has “been transparent with [CMS] about our approach under its unclear policies. We reject these claims and will contest them vigorously.”

This is the second lawsuit the department has filed against the insurer this month. The other lawsuit concerns separate but similar allegations filed under seal in 2011 by Benjamin Poehling, former finance director of UnitedHealthcare Medicare and Retirement.