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Health Care Investigations Archives

Health care providers: Fraud developments to watch in 2019

Health care fraud disputes were present throughout 2018. These cases included everything from individual physicians, nurses and other health care professionals fighting boards for their professional licenses to multi-million dollar Anti-Kickback Statute (AKS) violations cases — as discussed in a previous post, available here.

Former health care exec headed to trial

A health care executive known for running nursing and assisted living facilities in Chicago before expanding to Florida will begin trial within the next two weeks. The government has accused the former exec of his role in a scheme that allegedly defrauded Medicare of over $1 billion in false claims. The accused ran approximately 20 facilities and allegedly filed for claims with Medicare for services that were either never provided or unnecessary. The prosecution has also stated the business owner paid illegal kickbacks to physicians to encourage referrals to his facilities.

Healthcare fraud: What causes the government to file charges?

Healthcare fraud occurs when the government makes an accusation that someone filed false healthcare claims for financial gain. The government can accuse medical professionals throughout the healthcare field of a violation. Examples include:

Escobar decision and implied certification in FCA cases

The False Claims Act (FCA) makes it illegal to use false or fraudulent claims to seek payment from government sources, like Medicare and Medicaid. This law is complex. Court cases have questioned the best way to apply the FCA to establish a violation. These cases often require the plaintiff establish four elements: "(1) a false statement or fraudulent course of conduct, (2) made with scienter, (3) that was material, causing (4) the government to pay out or forfeit moneys due." The outcome of these cases often hinges on the scienter and materiality elements.

Diagnostic labs victims of “aggressive audit tactics”

Audit activity by government regulators and private payers has been on the rise. These investigations ramped up throughout 2017 and accelerated through 2018. The dramatic increase in audits is likely connected to the price cuts implemented with the new Medicare Part B.

HHS seeks repayment of sleep resupply claims over past six years

The United States Department of Health and Human Service’s (HHS) Office of Inspector General (OIG) recently released a report that states most Medicare claims from durable medical equipment supplies for payment for replacement positive airway pressure (PAP) device supplies were not in compliance with Medicare requirements.

Man expelled from Haiti to face healthcare fraud charges in U.S.

After over ten years of investigating and searching, the United States Department of Health and Human Services has recaptured and charged a man with healthcare fraud. In response to the initial charges made ten years ago, the accused fled. He left the country and, until recently, was in Haiti.

New York City officials' crackdown on home health care agencies

The New York City Department of Consumer Affairs (DCA) is following the recent practices of the United States Department of Labor. The federal government recently identified a prevalence of labor law violations within the home health care agency industry. As such, the DCA put together a group to investigate for local offenders.

NY nursing provider pays $1.65M to settle whistleblower claim

The New York state and federal government recently conducted an investigation into the operations of a local skilled nursing provider. The center under investigation provides long-term care services to patients in the community. These services can include adult day health care and skilled nursing visits to patients’ homes.

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