Archives: Fraud and Abuse

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Settlement With DOJ Opens a New Chapter For Tuomey

The cautionary tale of Tuomey (summaries can be found here and here), which illustrated the risks for hospitals structuring arrangements with physicians, is finally coming to a close. When the U.S. District Court for the District of South Carolina first ordered Tuomey Healthcare System, Inc. (“Tuomey”) to pay $237 million for violations of the Stark … Continue Reading

Largest National Health Care Fraud Take-Down in History Focuses on Medicare Part D

On the heels of its announcement that it is “hiring additional lawyers to look into taking more administrative actions against” physicians, the Office of Inspector General (OIG) recently filed 75 indictments and 14 complaints against various parties.  See the Fact Sheet.  The OIG’s “national sweep” yielded prosecution of $712 million in false billings and led … Continue Reading

OIG Puts Muscle Behind Its Alert

Only two days after releasing its latest fraud alert, a deputy director from HHS’s Office of Inspector General announced that the OIG will be hiring additional attorneys to look into taking more administrative actions against physicians in their individual capacity. This announcement emphasizes that the OIG means serious business – not only is the OIG … Continue Reading

OIG Warns Physicians Regarding Noncompliant Agreements

Tuesday, the OIG released a fraud alert advising physicians to ensure their compensation arrangements, such as medical director agreements, reflect fair market value for bona fide services the physicians actually provide, or they could potentially face liability under the Anti-Kickback Statute.  As part of the fraud alert, the OIG encouraged physicians “to carefully consider the … Continue Reading

CMS delays identifying overpayments. Can you?

The Centers for Medicare and Medicaid Services (CMS) continues to mull over the knotty problem of what it means to identify an overpayment from the government.  Healthcare providers do not have the same luxury. Five  years ago, the Affordable Care Act required a provider that received an overpayment from the government to report and repay it within 60 days of identifying the … Continue Reading

Release of the 2015 OIG Work Plan

Happy Halloween!  In addition to costumes and candy, October 31 saw the release of the 2015 Work Plan by the Office of Inspector General for Health and Human Services.  Always a lengthy document, the Work Plan can indicate areas that providers and suppliers want to monitor closely, as they are areas receiving attention from the government.  In … Continue Reading

DOJ Criminal Division Increasing Attention on Health Care False Claims

There may be more criminal cases involving healthcare fraud in the near future, as the U.S. Department of Justice has announced it will be ramping up its review of whistleblower cases involving alleged health care fraud.  In a recent speech Leslie R. Caldwell, Assistant Attorney General for the DOJ’s Criminal Division, announced that the U.S. Department of Justice was … Continue Reading

CMS Finalizes Medicare Part C and Part D Program Changes for Contract Year 2015: Moderate Deviations from Proposed Rule

On January 8, 2014, we noted several proposed changes to the Medicare Part C and D programs as delineated in CMS’ January 8th proposed rule (hereinafter “Proposed Rule”). On Monday, May 19, 2014, CMS issued the final rule, titled Medicare Program; Contract Year 2015 Policy and Technical Changes to the Medicare Advantage and the Medicare … Continue Reading

Is Your Name on the List?

Given the 880,000 names of physicians released by Medicare Wednesday, physicians who treat Medicare patients can expect their names to be on the list.  The list, searchable here, contains the name of the provider, the specialty area, the city, county and state as well as the total payments made to the provider by Medicare for … Continue Reading

Florida Proposes Pharmacy Audit Rights Legislation

The Florida legislature is currently considering proposed legislation that may affect the way in which managed care organizations, insurers, third-party payors, pharmacy benefit managers and other entities audit pharmacies in Florida.  The Florida House of Representatives, Health Innovation Subcommittee, is reviewing HB 745, which proposes to create a “Pharmacy audit bill of rights.”  The Health … Continue Reading

Is CMS Prepared for Evolving Medical Records Technology?

Health care fraud accounts for billions of the US health expenditure each year. This week HHS published a study addressing possible deficiencies in CMS’ capability to address fraud vulnerabilities and ensure the integrity of electronic health records (“EHR”) systems which CMS and its contractors use to pay Medicare claims. Concerns about whether CMS’ oversight and … Continue Reading

CMS and OIG Ring in the New Year with Final Rules on EHR Donations

On December 27, 2013, the Centers for Medicare and Medicaid Services (“CMS”) and the Office of Inspector General of the Department of Health and Human Services (“OIG”) published final rules (“Final Rules”) regarding the electronic health records (“EHR”) donations Stark Law Exception (42 C.F.R. 411.357(w)) and Anti-Kickback Statute Safe Harbor (“AKS Safe Harbor”) (42 C.F.R. … Continue Reading

Fourth Circuit Requires Penalties for FCA Violations, Even Where No Government Economic Damage Found

Author: Rebecca A. Worthington, Esquire In a decision sure to generate comment during the new year, the Fourth Circuit ruled in United States ex rel. Bunk v. Gosselin World Wide Moving, No. 12-1369, 2013 U.S. App. LEXIS 25225 (Dec. 19, 2013), that penalties of some amount must be awarded for violations of the civil False … Continue Reading

OIG Okays a Premium Assistance Program

Recently, many stakeholders in the healthcare industry have expressed interest in implementing programs that provide funding to help patients with insurance premium payments.  Until last week, it was unclear whether any type of premium assistance programs would be permissible under federal law.  Finally, in Office of Inspector General (OIG) Advisory Opinion 13-19 posted on December … Continue Reading

District Court Deals Major Blow to Halifax in Bank Busting Qui Tam Suit

On November 13, U.S. District Court Judge Gregory A. Presnell of the Middle District of Florida partially granted the U.S. government’s summary judgment motion against Halifax Hospital Medical Center (“Halifax”).  Judge Presnell ruled that Halifax failed to demonstrate that bonus compensation arrangements it made with medical oncologists satisfied a Stark Law exception.  Judge Presnell found … Continue Reading

Government Finds More Medical Services Unnecessary

In the September 2013 edition of the Cleveland Bar Journal, Colin Jennings and Tom Zeno described the government’s determination to challenge medical decision making as medically not necessary.   To read the article, visit Uncle Sam Becomes a Doctor:  Government Challenges to Medical Necessity. Recent prosecutions have been born out of their prediction. In October 2013, … Continue Reading

Tuomey Ordered to Pay $237 Million

Capping a case that has drawn the attention of healthcare lawyers and hospital executives nationwide, the U.S. District Court for the District of South Carolina has ordered Tuomey Healthcare System, Inc. (“Tuomey”) to pay over $237* million for violations of the Stark Law and False Claims Act arising from certain employment agreements between Tuomey and … Continue Reading

South Carolina AG: Tuomey not Permitted to Indemnify Trustees or Officers

The hits just keep coming for Tuomey Healthcare System, Inc. (“Tuomey”).  Tuomey is not permitted to indemnify its trustees or officers according to an opinion published by the Attorney General of South Carolina (“SC AG”) on September 3, 2013.  In May, 2013, the government requested approximately $237 million in damages after a jury found Tuomey … Continue Reading

Whistleblowers Can Be Anyone – Even Consultants

At first glance, Shands Healthcare’s (“Shands”) agreement to pay $26 million to the federal government and the State of Florida appears to be like all the other recently reported health care fraud settlements of whistleblower complaints. Upon closer inspection however, one significant difference stands out: the relator who initially brought the case against Shands was … Continue Reading

Non-Medicare Patients Only? Not Necessarily an Excuse. New OIG Opinion Shows Government Skepticism of “Carve-Out” Arrangements

Yesterday, the U.S. Dept. of Health and Human Services Office of Inspector General (“OIG”) clarified its stance on a growing practice – provider attempts to circumvent fraud and abuse laws by structuring financial arrangements to apply only to business concerning non-Federal program beneficiaries.  The OIG reiterated its dim view of this practice, citing an underlying … Continue Reading

DC District Court Grants CMS’ Motion to Dismiss Challenge to Regulations Expanding Limitations on Physician-Hospital Joint Venture Under Arrangements

On May 24, in Council for Urological Interests v. Sebelius et al., the United States District Court for the District of Columbia granted CMS’ motion to dismiss a challenge to 2008 regulations promulgated by CMS that: expanded the definition of an entity furnishing designated health services (“DHS”) to mean not only the billing organization but … Continue Reading

In Case You Were Wondering, CMS Takes Compliance Seriously: Lessons from a Medicare Part D Plan Sponsor’s Contract Termination for all Medicare Contractors and Providers

The Centers for Medicare and Medicaid Services (“CMS”) has historically used its authority to immediately terminate Part D plan sponsors only sparingly.  In fact, it has done so only once.  However, when it chooses to exercise this authority, plan sponsors should not count on courts to come to their aid.  In Fox Insurance Co., Inc. … Continue Reading

President’s Budget Proposes Limits on Physician Self-Referral for Certain Services

On April 10, 2013, President Obama released his proposed federal budget for fiscal year 2014.  Buried within the budget is a proposal to limit physician self-referrals for certain ancillary services.  Specifically, the budget proposes to encourage what it calls “more appropriate” use of ancillary services by limiting those providers who may self-refer for radiation therapy, … Continue Reading