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Showing 51 posts in Healthcare Fraud.

Upcoding & Unbundling In Healthcare Fraud

What Is Upcoding?

"Upcoding" occurs when a healthcare provider knowingly submits a claim with an incorrect billing code in order to increase reimbursement. A healthcare provider can do this by submitting Current Procedural Terminology (CPT) codes for lengthier, more expensive, or more serious procedures, equipment, or diagnoses than actually provided. For example, if a physician exaggerates the severity of their patient's condition in order to increase billings, that would be considered upcoding. Likewise, if a patient receives a brief consultation from a nurse, but the provider submits a claim for a higher cost consultation with a doctor, that would also be considered upcoding. More

The Anti-Kickback Statute and the False Claims Act: Working together to promote the responsible use of government funds

What is the Anti-Kickback Statute?

The Anti-Kickback Statute ("AKS")1 is a federal criminal law that prohibits the knowing exchange of valued items, services, or payments for referrals of goods or services reimbursable by federally funded healthcare programs. Any claim submitted in violation of the AKS is false, and therefore not reimbursable by federally funded healthcare programs. Accordingly, the AKS seeks to ensure patient health considerations drive medical decision-making, rather than monetary or other valuable incentives offered to providers. Combined with the False Claims Act ("FCA"),2 which allows individuals to sue parties who defraud the government, the two statutes provide a potent tool to combat health care fraud. More

Famous Whistleblowers and Their Impact on America

Whistleblowers have played a vital role in American history, bringing to light abuses and scandals in fields as diverse as pharmaceuticals and the military. Law enforcement agencies and government departments depend on whistleblowers to alert them to corporate and government corruption. That doesn’t always mean these entities have welcomed whistleblowers, however, especially when those people are highlighting problems within their organizations.

Fortunately, federal and state legislatures have enacted protections for whistleblowers, understanding the fundamental role they play in a democracy, and whistleblowers continue to come forward with valuable information about government and corporate misdeeds. Let's examine some of the most famous whistleblower cases and the role these courageous men and women have played in our nation's history. More

Carolina Physical Therapy and Sports Medicine, Inc. Settles False Billing Allegations and Agrees to Pay $790,000

US Attorney Sherri A. Lydon announced on May 9 that the United States Attorney's Office for the District of South Carolina has resolved claims of health care fraud with Carolina Physical Therapy and Sports Medicine, Inc. ("Carolina PT"). Carolina PT had nine physical therapy practices in South Carolina, in Columbia, Irmo, Lexington, Sumter, and Mount Pleasant respectively. More

Pharmaceutical Executive Found Guilty of Racketeering Conspiracy in Landmark Bribery Case Involving False Claims

On May 2, Insys Therapeutics ("Insys") founder, John Kapoor, and four co-defendants were found guilty of a racketeering conspiracy for running a nationwide bribery scheme involving the over-prescription of opioids. Kapoor is among the highest-ranking pharmaceutical executives to be held responsible and face trial for their part in the opioid crisis.  The charges carry up to 20 years in prison. More

Government Takes a Hard Line on Fraudulent Donations to Patient Assistance Programs

Last month, the Department of Justice ("DOJ") announced a settlement with two pharmaceutical companies – Astellas Pharma US, Inc. ("Astellas"), and Amgen Inc. ("Amgen") – resolving allegations that their "donations" to patient assistance programs violated the False Claims Act. The two companies agreed to pay a total of $124.75 million, and both entered into five-year corporate integrity agreements with the Office of Inspector General as part of their respective settlements. United States Attorney Andrew E. Lelling said that according to the allegations, the companies illegally subsidized the high costs of their own drugs at the expense of American taxpayers, and "[w]e will keep pursuing these cases until pharmaceutical companies stop engaging in this kind of behavior.” Multiple settlements related to similar investigations have already brought in hundreds of millions of dollars in only a few years' time. More

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Pharmaceutical Manufacturer US WorldMeds LLC Pays $17.5 Million to Settle False Claims Act Allegations

Pharmaceutical manufacturer US WorldMeds LLC (USWM), headquartered in Louisville, Kentucky, has agreed to pay $17.5 million to settle allegations that it violated the False Claims Act by paying kickbacks to both patients and physicians to induce prescriptions of its drugs Apokyn and Myobloc.  The Department of Justice (DOJ) announced the settlement on April 30, 2019. More

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Sutter Health Settles False Claims Act Allegations for $30 Million

Sutter Health, based in Sacramento, California, agreed to pay $30 million to settle allegations that the health system submitted inflated diagnosis codes to the Center for Medicaid Services (CMS) for Medicare Advantage beneficiaries.  The Department of Justice (DOJ) announced this in a press release on April 12, 2019.    More

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Durable Medical Equipment Provider Agrees To Pay $1.6 Million To Resolve False Claims Allegations

U.S. Attorney for Utah, John W. Huber, announced on December 11, 2018, that the durable medical equipment ("DME") company Western Medical Group agreed to pay $1,634,844 million to settle False Claims Act allegations.  The settlement is the result of two qui tam actions filed by whistleblowers in December 2013 and February 2014.  More

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Drug Maker Actelion Agrees to Pay $360 Million to Settle False Claims Act Investigation Into Kickbacks

The pharmaceutical company Actelion Pharmaceuticals US, Inc. ("Actelion"), based in South San Francisco, California, has agreed to pay $360 million to resolve claims that it illegally funneled kickbacks through a patient-assistance charity.  Federal prosecutors allege in a press release on December 6, 2018 that Actelion "illegally used a foundation as a conduit to pay the copays of thousands of Medicare patients taking Actelion's pulmonary arterial hypertension drugs." These actions are in violation of the False Claims Act.  More

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