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.”

Justice Department accuses Ontario-based hospital chain of cheating Medicare system

http://www.latimes.com/business/la-fi-prime-healthcare-20160525-snap-story.html

Centinela Hospital

The U.S. Justice Department has joined a whistle-blower case against Prime Healthcare Services, adding significant weight to allegations of widespreadMedicare overbilling at 14 of the company’s hospitals in California. A Los Angeles magistrate judge granted the agency’s request to intervene in the case Tuesday, one day after the government declared in a court filing that its investigation of the Ontario- hospital operator has “yielded sufficient evidence” that the facilities “submitted or caused the submission of claims to Medicare for unnecessary inpatient stays.”  Prime finds itself under federal scrutiny because of a whistle-blower complaint submitted in 2011 by Karin Berntsen, a registered nurse and director of quality and risk management at Alvarado Hospital in San Diego. Berntsen’s lawsuit accuses Prime of routinely making Medicare patients’ illnesses seem more severe than they really were in order to justify billing for additional services and increasing hospital admissions.

Individual liability, physician compensation among top fraud concerns

http://www.fiercehealthpayer.com/antifraud/story/individual-liability-physician-compensation-among-top-fraud-concerns/2016-03-21?utm_medium=nl&utm_source=internal&mrkid=lead.Id&mkt_tok=3RkMMJWWfF9wsRokuKrKde%2FhmjTEU5z14ukkX6a2lMI%2F0ER3fOvrPUfGjI4HRcJjPK%2BTFAwTG5toziV8R7LMKM1ty9MQWxTk

Fraud

Click to access Healthcare_Fraud_2015.pdf

Kickbacks, Bribes, and the Horrifying Truth Behind California’s Largest Medical Fraud Scandal

http://www.lamag.com/longform/kickbacks-bribes-and-the-horrifying-truth-behind-californias-largest-medical-fraud-scandal/

L to R: Michael Drobot, Tom Calderon, and Ron Calderon

Long Beach hospital owner Michael Drobot spent decades bilking the state of millions for unnecessary surgeries with allegedly bogus hardware, and plenty of doctors went along with him – See more at: http://www.lamag.com/longform/kickbacks-bribes-and-the-horrifying-truth-behind-californias-largest-medical-fraud-scandal/#sthash.flf2d3Ck.dpuf

 

51 hospitals reach $23M settlement as DOJ concludes cardiac device investigation

http://www.healthcaredive.com/news/51-hospitals-reach-23m-settlement-as-doj-concludes-cardiac-device-investig/414147/

Court reverses Sutter decision to terminate whistleblower doctor

http://www.bizjournals.com/sacramento/news/2015/07/08/court-reverses-sutter-decision-to-terminate.html?ana=e_du_wknd&s=article_du&ed=2015-07-11&u=FAuoHGaGEPdmk4X6khnaiw045b16af&t=1436632812

A Modesto doctor has won another legal victory against Sutter Health in a fight to get hospital privileges back after he complained about nursing practices.

A Modesto doctor has won another legal victory against Sutter Health in a fight to get hospital privileges back after he complained about nursing practices at Memorial Medical Center.

Physicians as whistleblowers: Doctors get rich by exposing fraud

http://www.jdsupra.com/legalnews/physicians-as-whistleblowers-doctors-70467/

Physician and Cash

Whistleblower suit against billionaire Soon-Shiong’s startup, NantHealth, calls its practices “fraudulent”

Whistleblower suit against billionaire Soon-Shiong’s startup, NantHealth, calls its practices “fraudulent”

Dr. Patrick Soon-Shiong