"A case now before the U.S. Supreme Court could mean fewer fraud lawsuits filed against healthcare providers. Or it could at least give them more clarity about what constitutes a violation of the law, experts say.

The Supreme Court announced Friday it would hear Universal Health Services v. United States ex rel Escobar, a case that focuses on one theory whistle-blowers and the government use in bringing False Claims Act cases to court. The act makes it illegal to knowingly submit fraudulent bills to the government, such as for services not actually performed.

In a variation of fraud claims, some whistle-blowers allege that providers submitted false claims by failing to follow certain regulations. Providers sometimes are held liable for not following such regulations even if the government never explicitly stated that following a regulation was a condition of payment, and even if the provider never explicitly vouched that it had complied with the regulation.

The Supreme Court will consider whether whistle-blowers and the government should be allowed to bring FCA cases under this theory, known as implied certification.

“It's a huge deal for healthcare providers,” said Larry Freedman, an attorney with Mintz Levin who defends providers in FCA cases. Legal claims based on implied certification are now “the major driver” of healthcare whistle-blower suits, he added.

Lower courts have been divided on the issue, with some saying it's unreasonable to sue organizations under the act for compliance issues arising from the thousands of pages of state and federal rules. Federal and state agencies, not the courts, should deal with such violations, some courts have said.

Allowing an implied certification argument in situations where it hasn't been clearly expressed that a regulation is a condition for payment could turn the False Claims Act into “a punitive sanction for use against minor regulatory or contractual violations,” Universal Health argues in court papers."

Read more at Modern Healthcare

"Dr. Michael Reilly's lawyer gave his client strong advice after reviewing a lucrative employment contract that the North Broward Hospital District offered him 15 years ago.

“I should throw this in the trash,” Reilly, a now-retired orthopedic surgeon, recalls the attorney telling him.

The contract, the lawyer said, had major problems, including that it violated the federal Stark law, which bars physicians from referring Medicare patients to hospitals, labs and other doctors that the physicians have financial relationships with unless they fall under certain circumstances.

Reilly didn't sign the contract.

That moment marked the beginning of Reilly's quest to hold North Broward Hospital District—a taxing district that operates five hospitals in Broward County in South Florida—accountable for alleged violations of the law. Reilly later filed a whistle-blower lawsuit against North Broward under the False Claims Act. In September, North Broward and the government settled the case for $69.5 million, with Reilly getting $12 million. North Broward did not admit to any wrongdoing. It declined to comment for this article.

Both plaintiff and defense attorneys predict that more False Claims Act cases alleging Stark violations are on the way, with whistle-blowers largely driving the U.S. Justice Department's enforcement—exponentially multiplying the government's regulatory eyes inside healthcare facilities. That's partly because two giant cases, involving Tuomey Healthcare System and Halifax Health, alerted potential whistle-blowers inside hospitals to the riches they could pocket by bringing such cases, some attorneys say.

In October, Tuomey in Sumter, S.C., agreed to settle with the government for $72.4 million, resolving allegations that it paid doctors in ways that rewarded them for referring patients to the hospital. Last year, Halifax in Daytona Beach, Fla., agreed to pay $85 million to settle allegations that it also had compensated physicians in illegal ways. Halifax did not admit to any wrongdoing. The whistle-blower in the Tuomey case got $18.1 million, while the whistle-blower in the Halifax case bagged $20.8 million."

Read more at Modern Healthcare

"More than 450 hospitals have settled with the government for more than $250 million as part of a yearslong, nationwide investigation into the suspected overuse of implantable cardiac devices, the U.S. Justice Department announced Friday.

The hospital systems involved include many of the country's largest, such as Adventist, Ascension Health, Banner Health, Catholic Health Initiatives, Community Health Systems, HCA, Tenet Healthcare Corp. and Universal Health Services among others.

At 42, HCA had the most hospitals involved in settlements and is paying the highest portion of the settlement, $15.8 million, followed by Ascension Health with 32 settling for $14.9 million and then Community Health Systems with 31 settling for $13 million.

None of those three systems admitted to any liability as part of their settlements.

Community Health Systems said in a statement Friday it agreed to the settlement to “avoid the continuing delay, uncertainty, inconvenience and expense of protracted litigation.”

“The issue involved a highly technical interpretation of a Medicare national coverage determination that was the subject of strong disagreement in the medical community," Community Health Systems said.

Ascension spokesman Nick Ragone said in a statement that Ascension was pleased to have reached an agreement with the Justice Department. “We are proud and appreciative of the cardiac care provided by our physicians, nurses and other caregivers nationwide to individuals in the communities we serve,” Ragone said."

Read more a Modern Healthcare

"Millennium Health LLC agreed to pay $256 million to resolve claims that it misrepresented the need for procedures and offered gifts to doctors in exchange for referrals.The biggest U.S. lab-testing company now plans to file for bankruptcy protection by Nov. 10, enabling it to turn over control of the business to its lenders, according to a person with knowledge of the matter.

The company has given the restructuring proposal to the holders of its $1.8 billion term loan and sent a copy to lawyers at the U.S. Department of Justice who are handling the settlement of the government’s case, said the person, who asked not to be named because the information isn’t public. Millennium will need to file its Chapter 11 petition with a bankruptcy court by Nov. 10, according to copies of resolved cases against the company that were unsealed Monday.

The payment will resolve allegations that Millennium violated the False Claims Act by having doctors order unnecessary urine, drug and genetic testing, according to a U.S. Department of Justice statement on Monday. The government accuses Millennium, a provider of urine-testing services to monitor prescription drug use and potential abuse, of misrepresenting to doctors the necessity of an $1,800 genetic test for pain management patients."

Read more at Bloomberg News

Too many to post individually over the last few days:

Bristol-Myers Squibb To Pay $14 Million To Settle Charges Of Bribery
California Woman Pleads Guilty In Medicare, Medicaid Fraud Scheme
Columbus Regional Agrees To Pay $35M Over Medicaid Fraud Claims
Atlanta Hospice Reaches $3 Million Settlement In Medicare Fraud Case
Government Accountability Office Report Highlights Improper Payments In Medicare, Medicaid



Bristol-Myers Squibb To Pay $14 Million To Settle Charges Of Bribery.

"WASHINGTON (AP) -- Bristol-Myers Squibb will pay $14.6 million to settle charges from U.S. regulators that its joint venture in China gave cash and other benefits to government health care providers to boost drug sales.

The Securities and Exchange Commission announced the settlement of civil charges Monday with the company, one of the largest drugmakers in the world. Bristol-Myers Squibb, based in New York, makes and sells prescription and over-the-counter medicines worldwide."

Read more at AP



California Woman Pleads Guilty In Medicare, Medicaid Fraud Scheme

"LOS ANGELES – A Placentia woman pleaded guilty Monday to a federal charge stemming from the operation of a hospice that submitted millions of dollars in fraudulent bills to Medicare and Medi-Cal.

Sharon Patrow, 44, entered her plea to a health care fraud count before U.S. District Judge S. James Otero, who set a May sentencing date. Patrow's mother, Priscilla Villabroza -- who is serving a 4 1/2-year term at a federal prison in Victorville for running a separate health care fraud scheme -- is also charged in the case.

The mother and daughter, along with four others, were charged in December with 25 health care fraud and money laundering counts, each of which carries a potential multiple-year prison sentence, according to the U.S. Attorney's Office.

The case involves the formerly Covina-based California Hospice Care, which Villabroza purchased in late 2007 while under investigation in the earlier case, prosecutors said.

Officials allege that between March 2009 and June 2013, California Hospice submitted nearly $9 million in fraudulent bills to Medicare and Medi- Cal for purportedly providing end-of-life care to patients who were, in fact, not dying. The public health programs paid nearly $7.5 million on those allegedly bogus bills."

Read more at OC Register



Columbus Regional Agrees To Pay $35M Over Medicaid Fraud Claims

"COLUMBUS — Last week, the hospital business in Georgia’s second-largest city received a double dose of financial misery. The first round of bad news centered on Columbus Regional Health. State Attorney General Sam Olens announced Friday that Columbus Regional and other related entities had agreed to pay Georgia and the United States up to $35 million to resolve allegations of false Medicaid claims.

Then the Columbus Ledger-Enquirer reported Saturday that the other hospital organization in town, St. Francis, has been told by the feds that it must repay $21.4 million and make major changes in the way it does business. The federal audit report came 10 months after St. Francis said it could not account for about $30 million on its financial books."

Read more at Albany Herald



Atlanta Hospice Reaches $3 Million Settlement In Medicare Fraud Case

"A Georgia hospice company has agreed to pay $3 million to resolve allegations it billed taxpayers for patients who were not terminally ill, the latest such settlement as federal officials target what they call a burgeoning number of abusive hospice schemes.


Guardian Hospice set aggressive targets to recruit and enroll patients it knew were not in the last months of their lives so it could collect Medicare payments, the federal government alleged. In agreeing to the settlement, the for-profit company, which serves the Atlanta area, did not admit liability."

Read more at AJC




Government Accountability Office Report Highlights Improper Payments In Medicare, Medicaid

WASHINGTON: Three health and safety net programs for the poor and elderly accounted for most of the federal government’s $124.7 billion in improper payments in fiscal 2014, the Government Accountability Office reported Thursday.

"The figure, which represents improper payments across 124 federal programs, is up roughly 20 percent from $105.8 billion in fiscal 2013, according to a new GAO report.

Most of the $19 billion increase resulted from erroneous payments under the Medicare, Medicaid and Earned Income Tax Credit programs. They account for more than 75 percent of the GAO’s government-wide improper payment estimate.

Improper payments are those made in error or in an incorrect amount and can include duplicate payments, those made without proper documentation or to ineligible recipients, and payments for ineligible goods and services.

They can result from fraud, unintentional clerical errors or a host of other reasons.

Nearly $1 trillion in improper federal payments have been made since 2003, when a federal law began requiring certain agencies to report the amounts."

Read more at McClacthyDC

'Nurses Registry and Home Health Corp. and the estate of its former owner, Lennie House, have agreed to a settlement against them for $16 million to resolve allegations of health care fraud, U.S. Attorney Kerry Harvey announced Thursday.
The settlement ends an investigation and False Claims Act litigation alleging that Nurses Registry, at the direction of House, fraudulently billed Medicare for medically unnecessary home health services, and services tainted by kickbacks provided by the company and House to local physicians and others who referred patients to Nurses Registry.

"For years, Nurses Registry abused its privileges as a provider in the Medicare program, and the trust of the medical community and general public," Harvey said in a statement. "This settlement returns ill-gotten gains to the Medicare Trust Fund and ensures that Nurses Registry will have no further opportunity to defraud federal health care programs."



Read more at Lexington Herald Leader

"Los Angeles prosecutors say a doctor was the ringleader in one of the state's biggest health fraud schemes that included unnecessary surgery by an untrained assistant that scarred patients for life.

Indictments unsealed Tuesday say a doctor and 14 associates bilked insurance companies out of $150 million in the scheme.

District Attorney Jackie Lacey says Dr. Munir Uwaydah was arrested in Germany on the 57-count indictment.

Eleven of his co-defendants appeared briefly in Los Angeles Superior Court and had not guilty pleas entered on their behalf. They were held on bail as high as $21.5 million."

Read more at KPCC

"Jaws dropped at news this summer that the federal government was seeking as much as $3.3 billion from drugmaker Novartis for allegedly paying kickbacks to pharmacies.

But the feds aren't the only ones trying to make Novartis pay up on false claims allegations, and it's not just Medicare dollars at stake. Eleven states are also parties to the lawsuit under the authority of their own false claims laws. They're seeking to recover money paid out by their state Medicaid programs.

The Novartis case is the latest example of states using their own false claims laws to pursue questionable Medicaid billings by drugmakers, healthcare providers and suppliers. Lured by the potential for big paydays, several states, including Maryland and Vermont, passed or expanded their false claims laws this year, bringing the number of states with their own false claims statutes to nearly 30, according to the Taxpayers Against Fraud Education Fund.

Many state false claims laws are similar to the federal law, financially penalizing those who knowingly submit false claims to state programs such as Medicaid. Many of the state laws also allow whistle-blowers to initiate lawsuits on behalf of the state."


Read more at Modern Healthcare

"The United States says Novartis AG (NOVN.VX) should pay as much as $3.35 billion in damages and civil fines because the Swiss drugmaker used kickbacks to boost sales of two drugs covered by Medicare and Medicaid.

In papers filed Monday night in Manhattan federal court, the government said it deserves that sum under the federal False Claims Act over alleged improper reimbursements for Exjade, used by patients who receive blood transfusions, and Myfortic, for patients with kidney transplants.

The government is seeking up to $1.52 billion in damages, representing triple the sums allegedly reimbursed and tainted by kickbacks between 2004 and 2013."

Read more at Reuters