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.
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.
New York State law requires individuals meet certain requirements before they can call themselves a pharmacist. These requirements include the applicant hold a license as well as have good moral character. Additional requirements include:
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:
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.
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.
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.
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.
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.
The Department of Justice (DOJ) accused a large drug company of paying kickbacks to medical professionals to encourage the physicians and nurse practitioners to prescribe their medications. The DOJ’s has accused the company of using kickbacks to encourage the prescription of a powerful, opioid pain medication approved by the Food and Drug Administration for cancer patients for the treatment of persistent pain for non-covered uses.