Mealey's Insurance Fraud
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May 21, 2019
11th Circuit Affirms Sentence For Fraud Scheme, Vacates Restitution Award
ATLANTA — A chiropractor’s 84-month sentence for engaging in a scheme to submit fraudulent claims to insurance companies for patients who were purportedly injured as a result of staged auto accidents was affirmed by an 11th Circuit U.S. Court of Appeals panel on May 20, but the panel vacated the amount of restitution he must pay because some claims may have been filed before he was hired by a clinic that participated in the scheme (United States v. Hal Mark Kreitman, No. 18-12838, 11th Cir., 2019 U.S. App. LEXIS 14760).
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May 21, 2019
Doctor Sentenced To 37 Months For Role In Unbundling Medicare Claims
BATON ROUGE, La. — The co-owner of a pain management clinic was sentenced by a federal judge in Louisiana on May 17 to 37 months in prison for his role in a fraudulent billing scheme that involved unbundling nonreimbursable office visits from minor surgical procedures and submitting the visits to Medicare (United States v. John E. Clark, No. 17cr85, M.D. La.).
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May 16, 2019
Medical Equipment Company Owner Sentenced For Submitting False Bills To Medicaid
MCALLEN, Texas— A woman who owned a medical equipment company was sentenced by a federal judge in Texas May 9 to 78 months in prison after she pleaded guilty to one count of health care fraud for fraudulently billing Texas Medicaid for incontinence supplies provided to beneficiaries (United States v. Anna Ramirez-Ambriz, No. 17cr56, S.D. Texas).
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May 16, 2019
Florida Clinic Owner Sentenced To 91 Months In Prison For Fraud Scheme
MIAMI — The owner of a Florida clinic was sentenced to 91 months in prison and ordered to pay $2.5 million in restitution by a federal judge in Florida on April 30 after she pleaded guilty to charges of conspiracy to commit health care fraud and conspiracy to defraud the United States by paying and receiving health care kickbacks (United States v. Juliette A. Tamayo, No. 18cr20535, S.D. Fla.).
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May 16, 2019
Cardiologist Appealing Sentence For Implanting Medically Unnecessary Stents
ASHLAND, Ky. — A cardiologist who was found guilty on one count of health care fraud and 10 counts of making false statements relating to health care matters on May 15 filed a notice of appeal in Kentucky federal court stating that he will ask the Sixth Circuit U.S. Court of Appeals to review his five-year prison sentence and $1.1 million restitution order (United States v. Richard E. Paulus M.D., No. 15cr15, E.D. Ky.).
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May 16, 2019
Man Sentenced For Submitting Bills For Unnecessary Genetic Testing For Elders
TRENTON, N.J. — A federal judge in New Jersey sentenced a man to 50 months in prison on May 13 after he pleaded guilty to one count of conspiracy to commit health care fraud and admitted using a nonprofit organization to convince elderly patients to undergo unnecessary genetic testing and submitting the bills to Medicare (United States v. Seth Rehfuss, No. 18cr134, D. N.J.).
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May 16, 2019
False Claims Act Suit Over Billing For Leftover Medications Dismissed
MIAMI — A federal judge in Florida on May 7 dismissed with prejudice a False Claims Act (FCA) lawsuit brought by two compound medication mixers against two companies, two doctors and an employee that accused the defendants of falsely billing Medicare, Tricare and other insurers for using leftover amounts of single-dose vial (SDV) medications, finding that the relator failed to allege that the defendants actually submitted claims for the leftover medications (United States, ex rel. Miguel A. Fernandez, et al. v. Miami Cancer Institute, et al., No. 17-24051-Civ-Scola, S.D. Fla., 2019 U.S. Dist. LEXIS 75529).
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May 15, 2019
Doctors’ Motion For Mistrial In Insurance Fraud Case Denied By Judge
HOUSTON — A federal judge in Texas on May 14 denied a motion for mistrial filed by two doctors who were found guilty on 21 counts of health care fraud by a jury, holding that two references to a co-defendant’s guilty plea and testimony from a government expert about a health care fraud conviction of a technician who worked for one of the defendant doctors were not prejudicial enough to warrant vacating the verdict (United States v. Harcharan Singh Narang, et al., No. H-17-290, S.D. Texas, 2019 U.S. Dist. LEXIS 80937).
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May 14, 2019
7th Circuit Says Interest From Bank Accounts Should Apply To Doctor’s Restitution
CHICAGO — A Seventh Circuit U.S. Court of Appeals panel ruled May 13 that a federal judge in Illinois erred when refusing to credit interest earned in four bank accounts containing funds that were obtained as part of a cardiologist’s insurance fraud scheme to his restitution, explaining that the U.S. marshals put the money from the accounts in an interest-bearing account that earned $225,000 and that pursuant to the doctor’s plea agreement with the government, the proceeds of all seized funds and forfeited property would be applied to the restitution amount (United States v. Sushil A. Sheth, No. 17-2741, 7th Cir., 2019 U.S. App. LEXIS 14173).
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May 9, 2019
5th Circuit Vacates Dismissal Of Former Hospice Care Worker’s False Claims Suit
NEW ORLEANS — A Fifth Circuit U.S. Court of Appeals panel on May 7 overturned a federal judge in Texas’ ruling dismissing a False Claims Act (FCA) suit brought by four former workers for a hospice care provider, finding that their claims for fraud satisfied the heightened pleading requirement of Federal Rule of Civil Procedure 9(b) and that the allegations in the complaint sufficiently showed that the misrepresentations their former employer made to Medicare were material (United States, ex rel. Deborah Lemon, et al. v. Nurses To Go Inc., et al., No. 18-20326, 5th Cir., 2019 U.S. App. LEXIS 13634).
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May 2, 2019
Drug Maker Agrees To Pay $17.5M To Resolve Suit Over Kickbacks
NEW HAVEN, Conn. — US WorldMeds LLC (USWM) agreed to pay $17.5 million to resolve allegations brought by two whistleblowers under the qui tam provisions of the False Claims Act (FCA) that accused the drug maker of engaging in a scheme to pay kickbacks to physicians and patients for prescriptions of the Parkinson’s disease drug Apokyn and cervical dystonia treatment Myobloc, according to an order entered in Connecticut federal court on April 30 (United States, ex rel. Brian Bennett v. US WorldMeds LLC, No. 13cv363, United States, ex rel. Robert Chinnapongse v. US WorldMed LLC, No. 16cv0804, D. Conn.).
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May 1, 2019
Couple Can Amend Third-Party Claims Against Insurance Agency, Judge Rules
NEW ORLEANS — A couple accused by their insurer of misrepresenting information on their application for a homeowners policy can amend their third-party complaint against the agency that obtained the policy, a federal judge in Louisiana ruled April 29 in denying the agency’s motion to dismiss, finding that the couple should be allowed to remedy deficiencies in their allegations for breach of contract, negligence and detrimental reliance (GeoVera Specialty Insurance Co. v. Mariette Joachin, et al., No. 18-7577, E.D. La., 2019 U.S. Dist. LEXIS 71661).
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April 30, 2019
5th Circuit Finds Woman Need Not Pay Restitution For Health Care Kickbacks
NEW ORLEANS — A Fifth Circuit U.S. Court of Appeals panel on April 26 affirmed a woman’s conviction for violating Medicare’s kickback statute based on referrals to a home health care agency she worked for but vacated an order requiring her to pay $1.9 million in restitution because the agency provided legitimate services to the patients (United States v. Kim Ricard, No. 18-30047, 5th Cir., 2019 U.S. App. LEXIS 12598).
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April 23, 2019
Company’s Motion To Intervene In Aetna’s Billing Suit Against Opioid Maker Denied
PHILADELPHIA — A federal judge in Pennsylvania on April 22 denied an insurance purchaser’s motion to intervene in a lawsuit brought by Aetna Inc. against the manufacturer of an opioid medication accused of billing the insurer for off-label prescriptions of Subsys, ruling that while the purchaser had standing, it lacked a financial interest in the litigation (Aetna Inc., et al. v. Insys Therapeutics Inc., et al., No. 17-4812, E.D. Pa., 2019 U.S. Dist. LEXIS 67648).
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April 22, 2019
Magistrate: Evidence Supports Inference On Statements Regarding Patient Payment
MIAMI — A federal magistrate judge in Florida on April 18 held that a health care clinic patient’s statement in a police report can support an inference that a clinic employee accused of participating in a scheme to submit fraudulent no-fault personal injury protection claims to an insurance company paid patients to receive treatment at the facility and paid patients to refer someone else to the clinic (Government Employees Insurance Co., et al. v. Quality Diagnostic Health Care Inc., et al., No. 18-cv-20101, S.D. Fla., 2019 U.S. Dist. LEXIS 67262).
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April 18, 2019
Home Health Care Employees Sentenced To Probation For Roles In Billing Scheme
PITTSBURGH — A federal judge in Pennsylvania on April 12 sentenced two home health care employees to up to five years’ probation and six months of home detention and ordered them to pay restitution for their roles in an $87 million fraudulent billing scheme that involved submitting claims to Pennsylvania’s Medicare program for services that were not rendered or contained insufficient supporting documentation (United States v. Autumn Brown, No. 18cr284, United States v. Brenda Lowry Horton, No. 18cr285, W.D. Pa.).
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April 18, 2019
Pennsylvania Panel Finds Fraud Defendant’s Sentence Modification Warranted
HARRISBURG, Pa. — A Pennsylvania appeals court panel on April 10 affirmed a trial court judge’s decision to modify an insurance fraud defendant’s sentence to up to four years in prison after her probation was revoked, holding that her appeal was untimely by one day and that incarceration would prevent future crimes (Pennsylvania v. Christina Marie Famiano, No. 2626 EDA 2018, Pa. Super., 2018 Pa. Unpub. LEXIS 1326).
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April 18, 2019
Divided 9th Circuit Panel Vacates Man’s Sentence For Health Care Fraud
PASADENA, Calif. — A 2-1 panel of the Ninth Circuit U.S. Court of Appeals on April 9 vacated a man’s 97-month sentence for 15 counts of health care fraud, holding that a federal court judge in California erred when calculating the defendant’s intended loss from the $8.4 million scheme (United States v. Michael Mirando, No. 17-50386, 9th Cir., 2019 U.S. App. LEXIS 10468).
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April 18, 2019
Government’s Suit Over Doctor’s Use Of Chelation Therapy Survives Dismissal
ROME, Ga. — A federal judge in Georgia on March 8 denied a doctor’s motion to dismiss a False Claims Act (FCA) lawsuit brought by the government, holding that the doctor’s argument that the use of chelation therapy was medically necessary is not enough to prove that the bills submitted for the treatment were legal (United States v. Charles C. Adams, M.D., et al., No. 18-cv-191-HLM, N.D. Ga., 2019 U.S Dist. LEXIS 61147).
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April 10, 2019
Department Of Justice: Charges Filed In 6 States For Fraud Schemes
WASHINGTON, D.C. — The U.S. Department of Justice announced April 9 that charges had been filed against 24 individuals in federal courts in California, Florida, New Jersey, Pennsylvania, South Carolina and Texas for their roles in health care fraud schemes that involved telemedicine companies inducing elderly patients to ask their physicians for durable medical equipment (DME) that was not medically necessary and then billing Medicare for the products, resulting in $1.2 billion in losses.