Date Posted: Monday, August 26, 2024

 

Home Health Providers to Pay $4.5M to Resolve Alleged False Claims Act Liability for Providing Kickbacks to Assisted Living Facilities and Doctors

 

Early July saw three home health agencies operating in Texas, Ohio, and Indiana, along with their owner, Evolution Health LLC (together, “the Companies”), agreeing to pay $4,496,330 to resolve allegations that they violated the False Claims Act by knowingly providing illegal kickbacks to assisted living facilities and physicians in exchange for Medicare referrals.

 

This settlement resolves allegations that, from 2013 to 2022, the three home health agencies provided lease payments and other valuable benefits, including wellness health services, sports tickets, and meals, to numerous assisted living facilities and their residents, as well as certain healthcare providers, in exchange for referrals of Medicare beneficiaries. The home health agencies then billed Medicare for the home health services they provided to the referred patients.

 

The Anti-Kickback Statute prohibits the provision of remuneration with the intent to induce referrals of government healthcare program business. The Anti-Kickback Statute is intended to ensure that medical providers' judgments are not compromised by improper financial incentives. Claims that are knowingly submitted in violation of the Anti-Kickback Statute are ineligible for payment and can violate the False Claims Act.

The Companies received credit under the department's guidelines for taking disclosure, cooperation, and remediation into account in False Claims Act cases. Among other actions, the Companies disclosed the conduct to the government, identified the individuals involved, and assisted in the determination of losses caused to Medicare.

 

The investigation and resolution of this matter illustrates the government's emphasis on combating healthcare fraud. One of the most powerful tools in this effort is the False Claims Act. Tips and complaints from all sources about potential fraud, waste, abuse, and mismanagement can be reported to the Department of Health and Human Services at 800-HHS-TIPS (800-447-8477).

 

The claims resolved by the settlement are allegations only. There has been no determination of liability.

 

Source: Home Health Providers to Pay $4.5M to Resolve Alleged False Claims Act Liability for Providing Kickbacks to Assisted Living Facilities and Doctors (2024, July 1). www.justice.gov.

 

The Grand Health Care System and 12 Affiliated Skilled Nursing Facilities to Pay $21.3M for Allegedly Providing and Billing for Fraudulent Rehabilitation Therapy Services

 

The Grand Health Care System and 12 affiliated skilled nursing facilities (collectively, “the Grand”) have agreed to resolve allegations that they violated the False Claims Act by knowingly billing federal healthcare programs for therapy services that were unreasonable, unnecessary, unskilled, or that simply did not occur as billed.

 

The settlement resolves allegations that, from as early as January 1, 2014, to September 30, 2019, the Grand knowingly submitted false claims for rehabilitation therapy for residents at 12 facilities Strauss Ventures owned and operated. During this period, Medicare Part A (Medicare's hospital insurance, which also pays for care in a skilled nursing facility in some circumstances) and TRICARE (the federal healthcare program for the Department of Defense) paid for such services at rates that varied based on the number of minutes of skilled rehabilitation therapy provided. The Grand allegedly submitted bills where the reimbursement claimed was based on providing more therapy than was reasonable and necessary, or in some cases where the therapists did not provide the amount of therapy reported.

 

As part of the settlement, the Grand admitted that certain now-former Grand management level employees implemented quotas that each of the 12 facilities was expected to reach, including quotas relating to beneficiaries' lengths of stay and to the percentage of beneficiaries billed at the highest reimbursement level. To meet these quotas, facilities often scheduled patients to receive therapy without consideration of what was reasonable and necessary based on the individual patients' clinical condition. In addition, the Grand directed that no more than three patients be discharged from any facility per week and instructed that no Medicare Part A patients should be discharged from rehabilitation therapy unless it had been discussed with corporate officials. The Grand admitted that this resulted in some Medicare beneficiaries “staying on therapy longer than was reasonable and medically necessary.”

 

The Grand acknowledged that there were various instances where supervisory officials, who did not personally evaluate or treat patients, set or adjusted the number of minutes of therapy that a Medicare patient would receive. The Grand also acknowledged that there were instances where supervisory personnel falsified the number of therapy minutes in the Grand's electronic recordkeeping system or instructed subordinates to do so, well after the therapy was allegedly rendered.

 

The settlement also resolves federal allegations that the Grand submitted false claims to Medicaid for services rendered at its Pawling, New York, nursing home between January 1, 2016, and June 30, 2021. These claims were allegedly false because the reimbursement rate was inflated by data inaccurately reflecting the degree of care, including rehabilitation therapy services, needed by Medicaid patients there.

 

The Grand has also entered into a five-year Corporate Integrity Agreement with the Department of Health and Human Services Office of Inspector General (HHS-OIG) that requires an independent review organization to annually assess the medical necessity and appropriateness of therapy services billed to Medicare.

 

The settlement resolves a whistleblower lawsuit filed under the qui tam provisions of the False Claims Act by two former providers of rehabilitation therapy at the Grand. The Act allows private persons to file civil actions on behalf of the government and share in any recovery. Under the settlement, the whistleblowers will receive approximately $4,047,000 of the settlement proceeds.

 

Source: The Grand Health Care System and 12 Affiliated Skilled Nursing Facilities to Pay $21.3M for Allegedly Providing and Billing for Fraudulent Rehabilitation Therapy Services (2024, July 10). www.justice.gov.

 

Kindred and Related Entities Agree to Pay $19.428M to Settle Federal and State False Claims Act Lawsuits Alleging Ineligible Claims for Hospice Patients

 

Gentiva, successor to Kindred at Home, has agreed to pay $19.428 million to resolve allegations that Kindred at Home and related entities (“Kindred”) knowingly submitted false claims and knowingly retained overpayments for hospice services provided to patients who were ineligible to receive hospice benefits under various federal healthcare programs. Gentiva's hospice operations, headquartered in Atlanta, include entities that previously operated Kindred at Home hospice locations under the names Avalon, Kindred, SouthernCare, and SouthernCare New Beacon.

 

The settlement resolves allegations made by the United States and the State of Tennessee in a consolidated complaint filed in 2021 against certain Kindred related entities alleging that, from 2010 until February 2020, the defendants knowingly submitted or caused to be submitted false claims for hospice services provided to Avalon hospice patients in Tennessee who were ineligible for the Medicare or Medicaid hospice benefit because they were not terminally ill. The settlement also resolves the complaint's allegations that the defendants improperly concealed or avoided Avalon's obligation to repay those hospice claims.

 

In addition, the settlement resolves allegations that certain Kindred, SouthernCare, and SouthernCare New Beacon hospice locations knowingly submitted, or caused to be submitted, false claims for hospice services provided to patients who were ineligible for hospice benefits under Medicare and other federal healthcare programs because the patients were not terminally ill. Those hospice locations included were Kindred's locations in Rhode Island, Texas, and Missouri; SouthernCare New Beacon's location in Alabama; and SouthernCare's locations in Alabama, Indiana, and Ohio. The settlement also resolves allegations that those Kindred, SouthernCare, and SouthernCare New Beacon locations knowingly and improperly concealed or avoided obligations to repay the foregoing hospice claims.

 

Further, the settlement resolves allegations that SouthernCare New Beacon allegedly violated the Anti-Kickback Statute by willfully paying remuneration to a consulting physician, between Oct. 1, 2016, and Oct. 1, 2022, to induce hospice referrals of Medicare beneficiaries to its Alabama location. The settlement of those allegations stems from a voluntary self-disclosure made by SouthernCare New Beacon Hospice. The Anti-Kickback Statute prohibits offering, paying, soliciting, or receiving remuneration to induce referrals of items or services covered by Medicare, Medicaid, and other federally funded healthcare programs. It is intended to ensure that medical providers' judgments are not compromised by improper financial incentives and are instead based on the best interests of their patients.

 

The settlement includes the resolution of claims in nine lawsuits brought under the qui tam or whistleblower provisions of the False Claims Act by various current and former Kindred employees. Under those provisions, a private party can file an action on behalf of the United States and receive a portion of any recovery. The share of the settlement to be received by the whistleblowers has not yet been determined.

 

The claims resolved by the settlement are allegations only. There has been no determination of liability.

 

Source: Kindred and Related Entities Agree to Pay $19.428M to Settle Federal and State False Claims Act Lawsuits Alleging Ineligible Claims for Hospice Patients (2024, July 18). www.justice.gov .

 

Owner of Home Healthcare Company Convicted of Multimillion Dollar Healthcare Fraud Scheme

 

A female owner was convicted Friday, July 19, 2024, following a nine-day jury trial in federal court in Boston in connection with a home healthcare fraud scheme.

 

She was convicted of one count of conspiracy to commit healthcare fraud, one count of healthcare fraud, and three counts of money laundering. The jury found the defendant not guilty on one count of money laundering conspiracy. Sentencing will be scheduled at a later date. She was arrested and charged along with her female co-defendant in February 2021.

 

From January 2013 to January 2017, she was a part owner and operator of Arbor Homecare Services LLC. She and others engaged in a conspiracy to use the home healthcare company to defraud MassHealth of at least $100 million.

 

Specifically, evidence at trial demonstrated that the home healthcare company failed to train staff, billed for home health services that were never provided or were not medically necessary, and billed for home health services that were not authorized. The home healthcare company, through this part owner, paid kickbacks for patient referrals, regardless of medical necessity. They also entered sham employment relationships with patients' family members to provide home health aide services that were not medically necessary and routinely billed for fictitious visits that she knew did not occur.

 

She used the laundered proceeds of the $100 million scheme to purchase a house and a Maserati.

 

Her co-defendant pleaded guilty to her role in the conspiracy in September 2022. She is scheduled to be sentenced on September 18, 2024, before a U.S. Senior District Court Judge on the case.

 

The charges of healthcare fraud, conspiracy to commit healthcare fraud, and money laundering each provide for a sentence of up to 10 years in prison, three years of supervised release, and a fine of up to $250,000 or twice the amount of the money involved in the laundering. Sentences are imposed by a federal district court judge based upon the U.S. Sentencing Guidelines and other statutory factors.

 

Source: Owner of Home Healthcare Company Convicted of Multimillion Dollar Healthcare Fraud Scheme (2024, July 22). www.justice.gov.

 

Santa Paula Doctor Pleads Guilty to Healthcare Fraud for Role in Hospice Scam That Bilked Medicare Out of $3.2 Million

 

A Ventura County physician who worked for two Pasadena hospices pleaded guilty recently to defrauding Medicare out of more than $3 million by billing the public health insurance program for medically unnecessary hospice services. He pleaded guilty to one count of healthcare fraud.

 

According to his plea agreement, from July 2016 to February 2019, the physician and a co-defendant schemed to defraud Medicare by submitting nearly $4 million in false and fraudulent claims for hospice services submitted by two hospice companies the co-defendant controlled.

 

Medicare only covers hospice services for patients who are terminally ill, meaning that they have a life expectancy of six months or less if their illness ran its normal course.

The physician falsely stated on claim forms that those patients had terminal illnesses to make them eligible for hospice services covered by Medicare, typically adopting diagnoses provided to him by hospice employees whether or not they were true. He did so even though he was not the patients' primary care physician and had not spoken to those primary care physicians about the patients' conditions. Medicare paid on the claims supported by his false evaluations and certifications and recertifications of patients.

 

In total, approximately $3,917,946 in fraudulent claims were submitted to Medicare, of which a total of approximately $3,289,889 was paid.

 

According to Medical Board of California records, he is a licensed physician in California but has been on probation with the Board since 2015 and is subject to limitations on his practice.

 

The United States District Judge on the case scheduled an October 25 sentencing hearing, at which time he will face a statutory maximum sentence of 10 years in federal prison.

 

The co-defendant remains at large. Yet another co-defendant, who allegedly recruited patients for the hospice companies in exchange for illegal kickbacks, has pleaded not guilty and is currently scheduled to go on trial on October 15.

 

An indictment contains allegations that a defendant has committed a crime. Every defendant is presumed to be innocent until and unless proven guilty in court.

 

Source: Santa Paula Doctor Pleads Guilty to Healthcare Fraud for Role in Hospice Scam That Bilked Medicare Out of $3.2 Million (2024, July 24). www.justice.gov.

 

Precision Lens Agrees to Pay $12 Million to the United States for Kickbacks to Doctors in Violation of the False Claims Act

 

Precision Lens and the estate of its former principal have agreed to pay the United States $12 million to resolve a case involving kickback payments to ophthalmic surgeons in violation of the False Claims Act and the Anti-Kickback Statute.

 

On February 27, 2023, a federal civil jury found that Precision Lens violated the False Claims Act and the Anti-Kickback Statute by paying kickbacks to ophthalmic surgeons to induce their use of Precision Lens products in cataract surgeries reimbursed by Medicare. Precision Lens provided kickbacks to physicians in the form of travel and entertainment, including high-end ski trips, fishing, golfing, hunting, sporting, and entertainment vacations, often at exclusive destinations. For many of the trips, physicians were transported to luxury vacation destinations on private jets, including trips to New York City to see a Broadway musical, the College Football National Championship Game in Miami, Florida, and the Masters Tournament in Augusta, Georgia. Precision Lens sold frequent flyer miles to its physician customers at a significant discount, enabling the physicians to take personal and business trips at well below fair market value.

 

The jury found that Precision Lens's conduct resulted in $43,694,641.71 in fraudulent claims submitted to Medicare. By operation of the statute, the court entered a $487,048,705.13 judgment against the company and its owner, which included treble damages and civil penalties under the False Claims Act. Following post-trial motions, the court reduced the judgment to $216,675,248.55. After the United States conducted a review of the defendants' financial position and ability to satisfy the judgment, the parties entered into a settlement agreement which requires Precision Lens and the estate to immediately pay $12 million to resolve the United States' claims.

 

 

With this resolution, the United States has collected nearly $27 million as a result of the misconduct alleged in this case.

 

The civil settlement arises from a case brought under the qui tam or whistleblower provisions of the False Claims Act. Under those provisions, a private party can file an action on behalf of the United States and receive a portion of a recovery.

 

Source: Precision Lens Agrees to Pay $12 Million to the United States for Kickbacks to Doctors in Violation of the False Claims Act (2024, July 25). www.justice.gov.

 

Sonal Patel, BA, CPMA, CPC, CMC, ICDCM, is CEO and Principal Strategist at SP Collaborative, LLC.

 

SP Collaborative, LLC was founded by Sonal Patel, BA, CPMA, CPC, CMC, ICDCM. Sonal utilizes her unique background and education in the humanities, fine art, and art history to complement her partnerships with her clients in healthcare.

 

SP Collaborative believes in the voices of all its partners and strives to maintain mutually beneficial relationships.

 

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