The following is a summary of selected federal Department of Health and Human Services’ Office of Inspector General (OIG) reports of fraud and abuse enforcement activity across the country.[1] The enforcement actions reported are based upon federal and individual states’ activity reported by OIG through its listserv on Enforcement Actions.
The summaries reflect areas of OIG’s and individual states’ current and recent enforcement activity.[2] Knowing where regulators’ attention is focused help health care providers identify areas of attention for compliance and risk assessment activities. Although not all the enforcement actions may be relevant to any one provider’s health care business, there may be some summaries that could be used as examples in compliance program education programs (“What to avoid”), or used in developing a risk management plan. (Note: An Acronym Key appears at the end of the Report.)
Of Note in this Issue:
- DME supplier agrees to settle AKS allegations that its provision of free masks used by sleep labs to diagnose sleep-related respiratory disorders induced the labs’ physicians to write referrals for Defendant’s branded masks. (December 27, 2023.)
- Health system employed specialists and other physicians to drive down stream referrals to the system in violation of the Stark Law. The System paid salaries significantly above fair market value (sometimes double private practice salaries), paid physicians bonuses based on their reaching a target of referrals, used volume of referrals in compensation payments, provided a valuation firm with false compensation figures in order to obtain a favorable opinion, and ignored repeated warnings from a valuation firm regarding the legal perils of overcompensating its physicians. The system agreed to a 5-year CIA. (December 20, 2023)
- Company providing remote cardiac monitoring services allegedly used its online enrollment portal and sales staff to misdirect clinical staff of ordering physicians to order higher-cost telemetry devices when physicians’ intent and medical necessity reflect a lower-cost device would be appropriate. The company also allegedly disregarded clinical staff’s written notes that the ordering physician intended to order a service other than telemetry.
- Among other allegations, a billing company owner allegedly acquired ownership of financially distressed hospitals, which were then used to bill for lab services that were performed not at the hospital, but at an independent lab. The defendant used the distressed hospitals’ private insurance contracts to obtain higher reimbursement for the tests performed at other labs. (December 19, 2023.)
- Medical device manufacturer settled allegations that it instructed, coached and encouraged medical providers to submit improper billing codes to Medicare for reimbursement of uses of its device that are not FDA-approved or FDA-authorized. In a related criminal matter, the CEO of the medical device manufacturer pled guilty to, among other things, introduction of misbranded and adulterated devices into interstate commerce. (December 12, 2023.)
- Hospital executive agrees to a five-year exclusion for her part in a conspiracy to violate the AKS when, among other things, she signed false certifications in Medicare cost reports regarding compliance with AKS when she knew of alleged MSO kickbacks to physicians who were induced to make lab referrals to her hospital. (December 5, 2023.)
December 27, 2023 OIG Listserv Release
Phillips Respironics Pays $2.4 Million for Allegedly Giving Kickbacks
CA. The Defendant, manufacturer of DME, allegedly paid kickbacks to sleep labs in violation of the FCA. Defendant allegedly provided sleep labs with free masks used to treat and diagnose sleep-related respiratory disorders to include the labs’ physicians to write referrals or prescriptions for its brand masks that suppliers would fill and bill to federal health care programs.
December 22, 2023 OIG Listserv Release
Carr’s Medicaid Fraud Division Obtains Guilty Plea in Fulton County
GA. The Defendant, founder of a behavioral health agency, allegedly billed Medicaid for psychotherapy sessions for recipients who were receiving services from another provider. Allegedly the Defendant submitted fraudulent claims on dates and times that recipients were in session with the other provider and never provided the services for those recipients himself.
Owner of Marketing Companies Admits Role in $24 Million Health Care Fraud and Kickback Scheme
NJ. The Defendant, owner of several marketing companies, admitted to allegations of his role in conspiracies to commit health care fraud and to pay and receive illegal kickbacks. The Defendant and his co-conspirators allegedly identified Medicare and TRICARE beneficiaries to target for expensive drugs and the marketing companies spoke by telephone to beneficiaries to pressure them to agree to try expensive medications, regardless of medical necessity. The employees would deliberately conceal the name of the prescribing doctor (whom the beneficiaries never met and the doctors often did not speak with the patients) to increase the likelihood the beneficiary would accept the medications. The Defendant and his companies allegedly paid kickbacks to telemedicine companies, which in turn paid kickbacks to doctors to obtain prescriptions for the medications and the Defendant. The Defendant allegedly transmitted to telemedicine companies the beneficiary medical information, the telephone call recordings made by the Defendant’s company in calls with beneficiaries, and pre-marked prescription pads for particular drugs that would yield exorbitant reimbursements. Drugs were chosen by the Defendant and his co-conspirators allegedly based on the reimbursement amount and not on medical need and the prescriptions were directed to pharmacies that the Defendant and his business partner had additional kickback arrangements.
Pharmaceutical Company Ultragenyx Agrees to Pay $6 Million for Allegedly Paying Kickbacks to Induce Claims for Its Drug Crysvita
CA. The Defendant, CA pharmaceutical company, allegedly paid for free genetic tests, plus a separate fee to receive test result information, for marketing purposes to induce prescriptions for its drug Crysvita and referrals of health care providers to the Defendant for furnishing or arranging for furnishing of the drug. The Defendant paid the genetic testing lab to conduct the required genetic tests at no cost to health care providers or patients. To provide the results to the health care providers, the Defendant’s sales personnel discussed the testing program with providers and delivered order forms for the tests to providers’ offices. The Defendant allegedly paid the testing lab to provide the Defendant with the test results that identified the name of the health care provider ordering the test, a de-identified patient ID number, the date the test was ordered and the results. The Defendant’s marketing department allegedly used the test reports to make sales calls to ordering providers. It was alleged that, as a result of this process, the Defendant paid kickbacks to beneficiaries in the form of free tests to induce purchase of its drug, and to the lab for the results reports to induce referrals to the Defendant, who would use the information for marketing its drug.
Nurse Practitioner Sentenced for $192M Medicare Fraud Scheme
FL. The Defendant allegedly used her position as a nurse practitioner to sign orders for medically unnecessary orthotic braces and genetic testing for Medicare beneficiaries who she never spoke to, examined or treated, and she falsified information on the orders about beneficiaries’ symptoms and injuries. Allegedly, telemarketing companies would contact Medicare beneficiaries to convince them to accept orthotic braces and genetic tests and would then send pre-filled orders for these products to the Defendant, who signed them, attesting she examined or treated the patients, despite never speaking to many of the patients. The Defendant allegedly used others, including non-license individuals, to sign her name to fraudulent orders. The Defendant allegedly ordered more cancer genetic tests for Medicare beneficiaries than any other provider in the nation and when, in response to the COVID-19 pandemic, telemedicine was expanded, she routinely billed for thousands of telemedicine visits she never performed, routinely billing over 24 hours of telemedicine in a single day.
December 21, 2023 OIG Listserv Release
Mississippi Man Sentenced to 18 Months in Federal Prison on Medicare Fraud Conspiracy Charges
MS. The Defendant, owner of a marketing company and patient broker, allegedly referred Medicare beneficiaries to labs in exchange for kickback payments. The Defendant allegedly paid marketers kickbacks to recruit Medicare patients to provide their Medicare information and genetic material, which the Defendant then sent to labs for Cancer genomic (“CGx”) testing. In exchange for the payment of kickbacks from the labs, he paid kickbacks to doctors for signed orders for CGx tests without regard to medical necessity for the tests, and he was aware that these tests had been obtained through kickbacks.
United Memorial Medical Center to Pay $2 Million Plus Additional Contingent Payments for Allegedly Causing False Claims Related to Excessive Cost Outlier Payments and Double Billing for Covid-19 Tests
TX. The Defendant formerly operated hospitals in Houston and agreed to make payments to settle FCA allegations related to its receipt of supplemental reimbursement, called “cost outlier” payments, when it rapidly increased its charges for inpatient care and under reported its charges on Medicare cost reports. This prevented the government from adjusting charges so they could reasonably reflect the Defendant’s actual costs. The Defendant is also alleged to have concealed and improperly avoided the obligation to reimburse federal health care programs for excessive outlier payments.
Outside the scope of this summary are the COVID-19 matters.
This was initiated through a Qui Tam action.
December 20, 2023 OIG Listserv Release
Grants Pass Physician and Affiliated Medical Practice Agree to Pay $115,000 to Settle Health Care Fraud Allegations
OR. The Defendants, medical doctor and his general practice, allegedly submitted claims to Medicare, TRICARE and VHA, that were coded as E&M when frequency-specific microcurrent (FSM) treatments were primarily provided. Medicare considers FSM as investigational treatment and does not provide coverage or payment.
Greenwich Psychologist Sentenced to 27 Months in Federal Prison for $2.6 Million Health Care Fraud Scheme
CT. The Defendant, a licensed psychologist, who, along with his wife maintained separate medical practices out of their home, allegedly assumed responsibility for submitting claims for health care programs for himself and his wife from their home office and at various SNFs. The Defendant allegedly billed for services he knew were not rendered, including billing for deceased patients, for dates of service he and/or his wife were out of the country and for dates of service when the Defendant was hospitalized. For approximately five years, the Defendant allegedly billed for services on every day but one, on 60 days he billed for more than 24 hours of service per day, and on 901 days he billed for more than 12 hours of service. The Defendant is to pay restitution, be excluded from Medicare and Medicaid for five years, and to report to prison. The Defendant’s wife entered into a civil settlement agreement where she agreed to pay restitution for funds she received for services she did not provide.
Georgia Man Admits Role in $127 Million Health Care Fraud and Kickback Scheme
NJ. The Defendant, operator of a marketing company, allegedly participated in a scheme with DME companies, telemedicine companies and doctors to submit false claims to health care benefit programs, including Medicare and TRICARE, based on a circular scheme of kickbacks and bribes. It is alleged the Defendant’s company identified Medicare and TRICARE beneficiaries to target for DME, its employees called the beneficiaries to pressure them to agree to accept DME, it paid commissions, bonuses, and incentives to encourage employees to convince as many beneficiaries as possible to accept DME regardless of medical necessity. The Defendant and his company allegedly paid kickbacks to telemedicine companies, which in turn, paid kickbacks to doctors to obtain doctors’ orders for DME, regardless of medical necessity, often without ever speaking to patients. The signed orders were allegedly steered by the Defendant and a co-conspirator to DME suppliers with which they had additional kickback arrangements, and the DME submitted claims to federal health care programs with proceeds being paid to the Defendant and his co-conspirator, in return for the signed doctors’ orders.
Indiana Health Network Agrees to Pay $345 Million to Settle Alleged False Claims Act Violations
IN. The Defendant, a healthcare network, agreed to resolve allegations it violated the FCA by knowingly submitting claims to Medicare for services referred in violation of the Stark Law. The allegations include that senior management at the Defendant illegally recruited physicians for employment for the purpose of capturing their “downstream referrals,” paid certain local physicians salaries that were significantly higher than they were receiving in private practice, provided false information to a valuation firm to obtain a favorable opinion, ignored warnings from a valuation firm related to overcompensating physicians, and were aware of the Stark Law requirements that employed physician compensation had to be at FMV and could not take into account the volume of referrals. The Defendant allegedly paid specialists excessive compensation in the form of financial performance bonuses that were based on reaching a target of referrals to the Defendant’s network.
The settlement included an agreement to enter into a 5-year CIA with OIG (see CIA section below).
December 19, 2023 OIG Listserv Release
Federal Jury Finds Pittsburgh-Area Nursing Homes Guilty of Healthcare Offenses
PA. The Defendants, two nursing homes, allegedly falsified staffing information to evade penalties for failure to meet Medicare and Medicaid’s conditions of participation related to safe staffing requirements to meet patient needs.
United States Files Complaint Against St. Elizabeth's Medical Center, Steward Medical Group and Steward Health Care System – Complaint alleges that defendants violated the Stark Law and submitted false claims to Medicare
MA. The Defendant, Steward, allegedly is an integrated health care system and one of the largest, private, for-profit health care networks in the nation. It owns the Defendants St. Elizabeth Medical Center (SEMC) and the Steward Medical Group (SMG). It is alleged that SEMC hired a cardiovascular surgeon at a compensation level that exceeded fair market value, as well as paid incentive compensation that varied and took into account the volume or value of his referrals to SEMC. The cardiologist allegedly made referrals to SEMC for services that were not eligible for payment due to Stark Law violations, and SEMC allegedly submitted claims for those services knowing that they were ineligible for payment.
The matter was initiated through a Qui Tam action.
BioTelemetry and LifeWatch to Pay More than $14.7 Million to Resolve False Claims Act Allegations Relating to Remote Cardiac Monitoring Services
PA. The Defendants allegedly submitted claims to federal health care programs for a higher level of remote cardiac monitoring than ordering physicians intended or than was medically necessary, with the effect of inflating the level of reimbursement paid to the Defendant. The Defendants allegedly used their online enrollment portal for their monitoring device, causing unwitting clinical staff to select options that would enroll the patient in the most expensive service, telemetry, even when the doctor intended to order a less expensive device. The Defendants’ sales staff allegedly instructed clinical staff to select the options that result in patients being enrolled for telemetry services, even when the sales personnel knew the clinic’s physicians intended to order less costly services. Additionally, the Defendants allegedly disregarded written notes the clinic personnel included in patient enrollments that specifically reflected the treating physicians’ intent to order a service other than telemetry.
The matter was initiated through a Qui Tam action.
December 18, 2023 OIG Listserv Release
Attorney General Ken Paxton’s Medicaid Fraud Control Unit Secures 14-Year Prison Sentence for Home Health Fraudster and Over $11 Million in Restitution
TX. The Defendant, operator of home health agencies owned by a co-conspirator, allegedly conspired with others to falsify patient files, pay marketers, and offer kickbacks to referring physicians for signing unnecessary home health orders. The conspirators allegedly submitted claims to government health care programs for services that were not provided, not medically necessary, or both.
Brooklyn Cardiologist Charged With Health Care Fraud And Bribery
NY. The Defendant, cardiologist, allegedly operated a medical clinic located in an area where many individuals have limited economic means and were insured through government programs. He allegedly made payments to other providers pursuant to purported “leases” for office space where the timing and the amount of payments bore no relation to the terms of the leases, such that it is alleged that the “lease payments” were made to induce other providers to refer patients to the Defendant’s staff who, at the Defendant’s direction, periodically traveled to the providers’ office, performed basic tests on the referred patients and convinced the patients to receive follow-up care at the Defendant’s clinic. On arrival at the Defendant’s clinic, it is alleged patients underwent a series of diagnostic tests and follow-up office visits that were not based on the patients’ actual treatment needs. The Defendant allegedly directed his staff to create documentation sufficient to justify subjecting patients to unnecessary peripheral vascular interventional procedures, and to fabricate the descriptions of patient symptoms in the practice’s office notes, varying symptoms across patients so it was not apparent the symptoms were fake. Additionally, the Defendant allegedly paid kickbacks for patient referrals and billed Medicare and Medicaid for medically unnecessary cardiac diagnostic and imaging studies, while directing staff to prepare fabricated medical records to make it appear that patients exhibited symptoms and complaints that justified performing the tests.
Florida Man Charged with Health Care Fraud, Wire Fraud, and Kickback Conspiracy
NJ. The Defendant and his company allegedly generated medically unnecessary prescriptions through a telemarking and telemedicine scheme. The Defendant and his company targeted Medicare beneficiaries for expensive drugs and used call center employees to contact beneficiaries to get them to agree to try expensive medications, such as pain creams, scare creams, eczema creams, migraine medication, as well as a “foot soak” combination of prescription medicines. The Defendant and his company transmitted recordings of telephone calls with beneficiaries, together with pre-marked prescription pads for particular high-cost drugs, to telemedicine companies that were paid kickbacks for every beneficiary referred for a prescription. The telemedicine companies paid doctors to approve the prescriptions. The Defendant directed the prescriptions to pharmacies with which his company had a kickback arrangement to be paid when the pharmacies received reimbursement from various federal health care programs.
Greenville Woman Sentenced to Federal Prison for Making Fraudulent Statements to Medicaid
MA. The Defendant, owner of a business that provided Applied Behavior Analysis therapy to treat Autism Spectrum Disorder, allegedly submitted electronic claims to Medicaid that falsely and fraudulently certified that services had been rendered and/or certified that services had been rendered in excess of what was actually provided to the beneficiary.
Orthopedic Surgeon Convicted of Health Care Fraud
MA. The Defendant allegedly defrauded health care benefit plans by falsely billing for orthopedic patient visits using billing codes for more complex (and expensive) services that were not provided; falsified medical records of patient visits to reflect examinations and services not performed; frequently billed for more than 60 and sometimes 90 patients per day, but used billing codes that reflected visit lengths more than could have been provided. He also allegedly ensured a high flow of patients by prescribing powerful, highly addictive opioids at a rate that made him one of the top prescribers of such drugs in MA.
Man Charged for $60M Health Care Fraud and Kickback Scheme
FL. The Defendant allegedly used his DME companies to bill Medicare for medically unnecessary orthotic braces that were ineligible for Medicare reimbursement; and referred doctors’ orders for medically unnecessary orthotic braces, genetic tests, and foot bath medications to other CME suppliers, pharmacies and labs in exchange for kickbacks and bribes. The Defendant also allegedly paid kickbacks and bribes to offshore call centers to obtain Medicare beneficiary information and falsified doctors’ orders. The Defendant allegedly paid kickbacks and bribes to purported telemedicine companies in exchange for doctors’ orders signed by telemedicine practitioners who did not examine or treat the Medicare beneficiary. It is also alleged the information and orders were used by the Defendant to submit claims through his own network of DME companies, as well as receiving kickbacks and bribes for referring those orders to other DME suppliers, pharmacies and labs.
Cambria County Woman Sentenced To 30 Months In Prison For Conspiracy To Commit Health Care Fraud
PA. The Defendant, CEO of a medical clinic treating chronic opioid patients, allegedly was repeatedly informed of the unlawful nature of the clinic’s practice of ordering multiple urine drug tests for each patient at every visit, despite a lack of medical necessity. The Defendant allegedly continued the clinic’s unlawful practice until search warrants were executed at the clinic’s locations and the clinic went out of business when it could no longer retain medical providers. The medically unnecessary urine drug tests were sent, whenever possible, to an in-house lab, according to allegations, which allowed the Defendant’s clinic to retain the proceeds, which were shared with the Defendant and a co-conspirator.
Two Men Sentenced for Fraudulent Rural Hospital Billing Scheme
FL. The Defendants were the owner and manager of hospitals and a billing company and the owner of a billing company. It was alleged that they conspired to unlawfully bill for lab tests (primarily urine drug tests) that were medically unnecessary and were fraudulently billed through rural hospitals in FL and MO, rather than the independent labs where the testing took place. The Defendants allegedly targeted and took control of financially distressed rural hospitals and then used them for billing to take advantage of private insurance contracts providing higher reimbursement rates for their hospitals, rather than for out-of-network labs. The claims allegedly were submitted falsely so that it appeared the hospitals conducted the lab tests when they were done by testing labs controlled by others. Additional allegations included that much of the testing was for vulnerable addiction treatment patients and patients of pain clinics, with samples obtained through kickbacks paid to recruiters and substance abuse treatment facilities. The tests billed by the Defendants were alleged to often be not medically necessary and performed at a frequency that far exceeded normal requirements for patient care, and it was alleged the Defendants performed repeated screens and definitive testing before the results of prior tests could have been reviewed or used by ordering providers.
December 14, 2023 OIG Listserv Release
Man Sentenced for $11.4M Medicare and Medicaid Fraud Scheme
LA. The Defendant, owner of DME supply company, allegedly billed Medicare and Medicaid for supplying respiratory support and nutritional support DME that were not medically necessary or not provided as represented. The Defendant allegedly directed the forgery of medical records, physician notes, and provider signatures in response to audits and record requests, to cover up the scheme.
December 12, 2023 OIG Listserv Release
Company Selling Migraine Treatment Device Agrees to Resolve Alleged False Claims Act Violations
IL. The Defendant, manufacturer of SphenoCath device, allegedly caused medical providers to submit false claims to Medicare for procedures for which SpenoCath was not FDA-approved or FDA-authorized. The Defendant allegedly instructed, coached and encouraged medical providers to submit improper billing codes to Medicare for reimbursement of services using the SpenoCath device. Payment to the U.S. by the Defendant is based on the Defendant’s ability to pay. In a related criminal matter, the Defendant’s CEO pled guilty to misdemeanor charges of introduction of misbranded and adulterated devices into interstate commerce and the CEO admitted that the Defendant did not seek approval or clearance from the FDA to distribute SphenoCath for the use in issue, and he admitted the Defendant did not conduct investigational studies recommended by the FDA for the device.
The matter was initiated through a Qui Tam action.
December 8, 2023 OIG Listserv Release
AG Moody Announces Arrest of Services Provider for More than $50,000 in Medicaid Provider Fraud
FL. The Defendant is the owner of a company providing personal support services and training to Medicaid recipients in daily living activities. He allegedly submitted falsified service logs in excess of hours of service actually performed and, using witness accounts, incomplete documentation and bank records. He is also alleged to have not paid workers for the total hours claimed to Medicaid, intentionally receiving the overpayments.
December 5, 2023 OIG Listserv Release
Med First Agrees to Pay $1,450,000 to Resolve Health Care Fraud Allegations in South Carolina Clinic
SC. The Defendant, clinic, agreed to settle allegations that it operated a pill mill and falsely filed claims for medically unnecessary urine drug testing (UDT), as well as for lengthy and complex office visits that were not performed. It was alleged the Defendant performed presumptive and definitive UDT at nearly every patient office visit for opioid therapy patients and that the Defendant performed the repetitive testing without first conducting individualized determinations of need or risk profile, and that the results of the UDT were often disregarded when considering opioid prescriptions that were rarely altered. Additionally, the Defendant allegedly billed E&M visits at a higher level of complexity than was actually provided to patients.
The matter was initiated by a Qui Tam action.
Doctor Charged in $14M Medicare and TRICARE Fraud Scheme
WA. The Defendant, physician, allegedly signed fraudulent medical documentation and orders that were then sold to DME companies that used the fraudulent documentation and orders to bill Medicare and TRICARE. The Defendant allegedly received and signed medical documentation and orders as part of a telemarketing scheme where telemarketers contacted beneficiaries to obtain identifying and medical information, which was then used to create fake medical records to support a doctor visit that never took place, as well as medical orders for DME based on that false visit. The beneficiaries included individuals who had no desire or medical need for DME, and some beneficiaries would not have been eligible for the DME as they were in hospice or lacked the limb for which the DME was ordered. In addition to the fraudulent DME payments, the Defendant received Medicare and TRICARE payments for fraudulent telemedicine visits that never took place.
Hospital Executive and Three Texas Physicians to Pay Over $880,000 to Settle Kickback Allegations Involving Laboratory Testing
TX. The Defendant-physicians allegedly received payments from a purported MSO in return for ordering laboratory tests from a critical access hospital and a clinical lab. The Defendant-hospital executive allegedly knew that her hospital paid commissions to recruiters who used MSOs to pay kickbacks to doctors to induce lab testing referrals and she allegedly signed false certifications in Medicare cost reports regarding compliance with AKS when she knew of the alleged MSO kickbacks.
The Defendant-hospital executive agreed to be excluded from participation in federal health care programs for five years. The Defendant-physicians made payments to resolve allegations against them.
The Defendants agreed to cooperate with the DOJ’s investigations of, and litigation against, other participants in the alleged schemes.
December 4, 2023 OIG Listserv Release
Philadelphia Pharmacy Pleads Guilty to More than $500,000 in Fraudulent Insurance Claims as Part of Prescription Medication Scam
PA. The Defendant, pharmacy through its owner, pled guilty to allegations that they billed Medicaid and other providers for prescription medications that were never provided to patients; billed for brand-name medications, but dispensed generic versions; requested physicians to prescribe specific unnecessary and expensive medications; asked physicians to change medications to more expensive replacements; and refilled expensive medications and billed insurance companies for refills without the knowledge of the patient and without ever dispensing the refills, but keeping the payment.
Man Charged in $148M Medicare and Medicaid Fraud Scheme
LA. The Defendant, co-owner and CEO of a diagnostic lab, allegedly billed Medicare and Medicaid for definitive testing of 15 substances in urine specimens it received, regardless of the patients’ treatment plans, history or the request of the referring provider. Allegations also include that the Defendant’s lab wrote off patient copays; directed lab staff to fill out and submit order forms on providers’ “behalf,” concealing the true nature, permissibility, and extent of testing from providers; orchestrating a pass-through billing scheme using hospitals; and paying kickbacks to physicians disguised as laboratory ownership interests.
Lab Owner Pleads Guilty to $1.7 Million COVID-19 Test Fraud Scheme
TX. The Defendant, owner of a lab, and his co-conspirators, which included medical providers and others with access to patient information, allegedly shared Medicare beneficiary information so the Defendant’s lab could bill Medicare for over the counter COVID-19 tests that were reimbursed by Medicare. In exchange for the information, the Defendant allegedly paid kickbacks to the medical providers and other individuals, trying to conceal the kickbacks through the use of passthrough arrangements and cash payments.
CORPORATE INTEGRITY and INTEGRITY AGREEMENTS – NEW CASES
December 18, 2023 – effective date: Reported December 20, 2023
COMMUNITY HEALTH NETWORK, INC.
* 5- year Corporate Integrity Agreement
* Covered Conduct: Allegations that the health care system violated the Stark Law’s anti-referral requirements by employing physicians at salaries that were significantly above FMV rates, included the volume of referrals in compensation considerations, provided false information to a valuation firm to obtain a favorable opinion, and ignoring warnings from a valuation firm on the dangers of excessive compensation paid to employed physicians. Among other things, the CIA requires Community Health Network to review all current and future “Focus Arrangements” (employment agreements with referral sources) to assess compliance with AKS and Stark Law and to take appropriate action when suspected violations are identified.
See December 20, 2023, summary above Indiana Health Network Agrees to Pay $345 Million to Settle Alleged False Claims Act Violations.
HHS-OIG ADVISORY OPINIONS ISSUED DURING DECEMBER, 2023
2023-11 – posted December 27, 2023
Favorable Opinion regarding proposed subsidization of certain Medicare cost-sharing obligations in the context of a clinical trial.
2023-10 – posted December 20, 2023:
Favorable Opinion regarding the use of a “preferred hospital” network as part of Medigap policies where the insurance company contracts with a PHO to provide discounts on otherwise applicable Medicare inpatient deductibles for its policyholders and the insurance company would provide a premium credit of $100 off the next renewal premium to policyholders who use the network hospital for an inpatient stay.
2023-09 – posted December 18, 2023
Favorable Opinion regarding the use of a “preferred hospital” network as part of Medigap policies where the insurance company contracts with a PHO to provide discounts on otherwise applicable Medicare inpatient deductibles for its policyholders and the insurance company would provide a premium credit of $100 off the next renewal premium to policyholders who use the network hospital for an inpatient stay.
Key:
AG = Attorney General
AKS = Anti-Kickback Statute
CIA = Corporate Integrity Agreement
CMP = Civil Monetary Penalties
CMS = Centers for Medicare and Medicaid Services
CPT = Current Procedural Terminology Codes
DOJ = United States Department of Justice
DME = Durable Medical Equipment
E&M = Evaluation & Management services
FEHBP = Federal Employees Health Benefits Program
FMV = Fair Market Value
DOJ = United States Department of Justice
FCA = False Claims Act
FWA = Fraud, Waste & Abuse
HHS = Department of Health and Human Services
HRSA + HHS’s Health Resources and Services Administration
IA = Integrity Agreement
LTC = Long Term Care (usually facilities)
MCO = Managed Care Organization (typically Medicaid)
MFCU = Medicaid Fraud Control Unit
MSO = Management Services Organization
NH = Nursing Home
NPI = National Provider Identifier
OIG = Office of Inspector General in HHS
OT = Occupational Therapy
PBM = Pharmacy Benefit Managers
PHO = Preferred Hospital Organization
PT = Physical Therapy
SNF = Skilled Nursing Facility
[1] Not included in the summaries are prosecutions related solely to drug diversion and inappropriate prescriptions, patient fiscal or physical abuse, or non-health care related matters such as money laundering as a specific allegation that may be in conjunction with an alleged fraud or misuse of COVID-19 relief funds. The summaries also do not include enforcement announcements of arrests with no report of an indictment or civil complaint or announcements related to sentencing following a conviction or guilty plea.
[2] The summaries should be considered to reflect allegations and not necessarily be considered to be statements of fact.
