Category

Qui Tam Litigation

Florida Compounding Pharmacy Agrees To Pay At Least $775,000 To Resolve False Claims Act Allegations

By | Business Fraud, False Claims Act Litigation, Qui Tam Lawsuits, Qui Tam Litigation, whistleblower lawyers

The U.S. Department of Justice announced on February 14, 2019 that  Vital Life Institute LLC (formerly known as AgeVital Pharmacy LLC), located in Sarasota, Florida, and its two owners, have agreed to pay at least $775,000 to resolve claims that they violated the False Claims Act by engaging in an illegal kickback scheme to induce the referral of compounded drug prescriptions for TRICARE and Medicare beneficiaries. AgeVital and the owners also agreed to pay additional amounts in the event certain contingencies are triggered.

The government alleged that AgeVital, at the direction of its owners, paid kickbacks to a third-party marketing company to solicit prospective patients for compounded drug prescriptions regardless of patient need. The marketing company arranged for prescribers to sign those prescriptions, which were then referred to AgeVital to be filled. The kickbacks to the marketing entity allegedly consisted of a substantial share of the pharmacy’s TRICARE and Medicare reimbursements. The Anti-Kickback Statute prohibits, among other things, the knowing and willful payment of any remuneration to induce the referral of services or items that are paid for by a federal health care program.  Claims submitted to federal health care programs in violation of the Anti-Kickback Statute can subject the violator to liability under the False Claims Act.

The settlement resolves a lawsuit filed in federal court in Tampa, Florida, by a patient who allegedly received unwanted compounded medications from AgeVital that were billed to Medicare.  The lawsuit was filed under the qui tam or whistleblower provisions of the False Claims Act.  The Act permits private parties to bring a lawsuit on behalf of the United States for false claims and to share in any recovery.  The whistleblower will receive at least $139,500 of the settlement.

The lawsuit is captioned United States ex rel. Knopf v. AgeVital Pharmacy, LLC et al., Case No. 8:15-cv-2591-T-36JSS (M.D. Fla.).

Source

If you have information regarding false claims having been submitted to Medicare, Medicaid, TRICARE, other federal health care programs, or to other federal agencies/programs, and the information is not publically known and no actions have been taken by the government with regard to recovering the false claims, you should promptly consult with a False Claims Act attorney (also known as qui tam attorneys) in your U.S. state who may investigate the basis of your False Claims Act allegations and who may also assist you in bringing a qui tam lawsuit on behalf of the United States, if appropriate, for which you may be entitled to receive a portion of the recovery received by the U.S. government.

Email us at info@businesslitigationcontingencylawyers.com or telephone us toll-free in the United States at 800-756-2143 to find qui tam lawyers who may handle your False Claims Act matter on a contingency basis.

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Pathology Lab Settles False Claims Act Allegations For $63.5M

By | Business Fraud, False Claims Act Litigation, Qui Tam Lawsuits, Qui Tam Litigation, whistleblower lawyers

The U.S. Department of Justice announced on January 30, 2019 that pathology laboratory company Inform Diagnostics has agreed to pay $63.5 million to settle allegations that it violated the False Claims Act by engaging in improper financial relationships with referring physicians. Inform Diagnostics, formerly known as Miraca Life Sciences Inc., is headquartered in Irving, Texas, and was a subsidiary of Miraca Holdings Inc., a Japanese company, during the relevant period. In 2017, majority ownership of the company changed and the company was renamed.

The settlement resolves allegations that Inform Diagnostics violated the Anti-Kickback Statute and the Stark Law by providing to referring physicians subsidies for electronic health records (EHR) systems and free or discounted technology consulting services. The Anti-Kickback Statute and the Stark Law restrict the financial relationships that health care providers, including laboratories, may have with doctors who refer patients to them. Although regulations adopted by the Department of Health and Human Services (HHS) in 2006 included provisions that allowed laboratories to provide EHR donations to physicians under certain conditions, the United States alleged that Inform Diagnostics violated those conditions. HHS withdrew those exemptions for laboratories in 2013.

The allegations stem from three lawsuits that were filed under the qui tam, or whistleblower, provisions of the False Claims Act, which permit private citizens to bring suit on behalf of the United States for false claims and share in any recovery. The whistleblowers’ share of the settlement has not yet been determined.

In announcing the settlement, an Assistant Attorney General of the U.S. Department of Justice’s Civil Division stated, “The Department of Justice has longstanding concerns about improper financial relationships between health care providers and their referral sources because those relationships can alter a physician’s judgment about the patient’s true health care needs and drive up health care costs for everybody. In addition to yielding a substantial recovery for taxpayers, this settlement should deter similar conduct in the future and help make health care more affordable.”

The case was investigated by the Civil Division’s Commercial Litigation Branch, the U.S. Attorney’s Office for the Middle District of Tennessee, the U.S. Attorney’s Office for the Middle District of Florida, the Department of Health and Human Services Office of Inspector General, and the Federal Bureau of Investigation. The cases are captioned United States ex rel. Dorsa v. Miraca Life Sciences, Inc., Case No. 13-cv-1025 (M.D. Tenn.); United States ex rel. LPF, LLC v. Miraca Life Sciences, Inc., et al., 3:16-cv-1355 (M.D. Tenn.); and United States ex rel. Heaphy, et al. v. Miraca Life Sciences, Inc., 3:18-cv-1027 (M.D. Tenn.).

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If you have information regarding false claims having been submitted to Medicare, Medicaid, TRICARE, other federal health care programs, or to other federal agencies/programs, and the information is not publically known and no actions have been taken by the government with regard to recovering the false claims, you should promptly consult with a False Claims Act attorney (also known as qui tam attorneys) in your U.S. state who may investigate the basis of your False Claims Act allegations and who may also assist you in bringing a qui tam lawsuit on behalf of the United States, if appropriate, for which you may be entitled to receive a portion of the recovery received by the U.S. government.

Email us at info@businesslitigationcontingencylawyers.com or telephone us toll-free in the United States at 800-756-2143 to find qui tam lawyers who may handle your False Claims Act matter on a contingency basis.

BusinessLitigationContingencyLawyers.com – The Practical Solution For Business Litigation

U.S. Announces $269.2 Million Settlement With Walgreens In Two Civil Healthcare Fraud Lawsuits

By | Business Fraud, False Claims Act Litigation, Qui Tam Lawsuits, Qui Tam Litigation, whistleblower lawyers

The Department of Justice U.S. Attorney’s Office Southern District of New York (Manhattan U.S. Attorney) announced on January 22, 2019 that the United States filed and settled two healthcare fraud lawsuits against national pharmacy chain Walgreens Boots Alliance, Inc. (“Walgreens”) in which Walgreens must pay the United States and state governments a total of $269.2 million.

First Settlement – Insulin Pens

The U.S. alleged that Walgreens routinely submitted false days-of-supply data to federal healthcare programs when it sought federal reimbursement for insulin pens it dispensed to federal beneficiaries who did not need them. The U.S. alleged that Walgreens engaged in two practices that resulted in the fraudulent submissions: Walgreens configured its electronic pharmacy management system to prevent its pharmacists from dispensing less than a full box of five insulin pens, even when patients did not need that much insulin; and when a full box of insulin pens exceeded the federal healthcare program’s limit on the total days of supply (i.e., the total number of daily doses) that could be dispensed and reimbursed at that time, Walgreens allegedly evaded this restriction by falsely stating in its reimbursement claims that the total days of supply did not go over the limit. The U.S. contended that as a result, federal healthcare programs paid Walgreens millions of dollars for insulin that many beneficiaries did not actually need, and substantial quantities of valuable medication were wasted. The U.S. alleged that this conduct also opened the door to potential healthcare risks and abuse, such as the improper resale of insulin pens on the Internet.

The settlement requires Walgreens to pay approximately $168 million to the U.S., and Walgreens agreed separately to pay approximately $41.2 million to state governments. The settlement was approved on January 16, 2019 by a federal judge and was unsealed on January 22, 2019.

Second Settlement – Discount Drug Pricing

The U.S. alleged that Walgreens operated a program called the Prescription Savings Club (“PSC”) under which customers received discounts when they ordered drugs from Walgreens. Medicaid regulations required Walgreens to seek Medicaid reimbursement only at the lowest of certain drug price points, including the “usual and customary price” (“U&C price”). Medicaid rules of many states defined the U&C price as the price offered through discount programs like the PSC. Contrary to these requirements, Walgreens allegedly did not disclose to Medicaid the discount drug prices it offered customers through the PSC when it sought reimbursement from Medicaid. As a result, Medicaid programs paid Walgreens more in reimbursements than it would have paid had Walgreens disclosed the lower PSC prices.

The settlement requires Walgreens to pay a total of $60 million, of which approximately $32 million is to the United States and approximately $28 million will go to state governments. The second settlement was approved on January 15, 2019 by a federal judge and was also unsealed on January 22, 2019.

In both settlements, Walgreens admitted and accepted responsibility for conduct the U.S. alleged in its complaints under the False Claims Act. Both cases arose from lawsuits filed by whistleblowers under the False Claims Act.

Source

If you have information regarding false claims having been submitted to Medicare, Medicaid, TRICARE, other federal health care programs, or to other federal agencies/programs, and the information is not publically known and no actions have been taken by the government with regard to recovering the false claims, you should promptly consult with a False Claims Act attorney (also known as qui tam attorneys) in your U.S. state who may investigate the basis of your False Claims Act allegations and who may also assist you in bringing a qui tam lawsuit on behalf of the United States, if appropriate, for which you may be entitled to receive a portion of the recovery received by the U.S. government.

Email us at info@businesslitigationcontingencylawyers.com or telephone us toll-free in the United States at 800-756-2143 to find qui tam lawyers who may handle your False Claims Act matter on a contingency basis.

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Over $2.8 Billion Recovered From False Claims Act Cases In Fiscal Year 2018

By | Business Fraud, False Claims Act Litigation, Qui Tam Lawsuits, Qui Tam Litigation, whistleblower lawyers

The U.S. Department of Justice announced on December 21, 2018 that the Department obtained more than $2.8 billion in settlements and judgments from civil cases involving fraud and false claims against the government in the fiscal year ending September 30, 2018.  Recoveries since 1986, when Congress substantially strengthened the civil False Claims Act, now total more than $59 billion.

Of the $2.8 billion in settlements and judgments recovered by the Department of Justice this past fiscal year, $2.5 billion involved the health care industry, including drug and medical device manufacturers, managed care providers, hospitals, pharmacies, hospice organizations, laboratories, and physicians.  This is the ninth consecutive year that the Department’s civil health care fraud settlements and judgments have exceeded $2 billion.  The recoveries included in the $2.5 billion reflect only federal losses but, in many of these cases, the Department was instrumental in recovering additional millions of dollars for state Medicaid programs.

In addition to combating health care fraud, the False Claims Act serves as the government’s primary civil remedy to redress false claims for federal funds and property involving a multitude of government operations and contracts.  These areas range from defense and national security to import tariffs and small business programs.

In 1986, Congress strengthened the Act by increasing incentives for whistleblowers to file lawsuits alleging false claims on behalf of the government.  These whistleblower, or qui tam, actions comprise a significant percentage of the False Claims Act cases that are filed.  If the government prevails in a qui tam action, the whistleblower, also known as the relator, receives up to 30 percent of the recovery.  Whistleblowers filed 645 qui tam suits in fiscal year 2018.

Of the $2.8 billion in settlements and judgments reported by the government in fiscal year 2018, over $2.1 billion arose from lawsuits filed under the qui tam provisions of the False Claims Act.  During the same period, the government paid out $301 million to the individuals who exposed fraud and false claims by filing these actions.

Source

If you have information regarding false claims having been submitted to Medicare, Medicaid, TRICARE, other federal health care programs, or to other federal agencies/programs, and the information is not publically known and no actions have been taken by the government with regard to recovering the false claims, you should promptly consult with a False Claims Act attorney (also known as qui tam attorneys) in your U.S. state who may investigate the basis of your False Claims Act allegations and who may also assist you in bringing a qui tam lawsuit on behalf of the United States, if appropriate, for which you may be entitled to receive a portion of the recovery received by the U.S. government.

Email us at info@businesslitigationcontingencylawyers.com or telephone us toll-free in the United States at 800-756-2143 to find qui tam lawyers who may handle your False Claims Act matter on a contingency basis.

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Target Agrees To Pay $3 Million To Resolve Allegations Of Operating An Unauthorized Automatic Refill Program In Massachusetts

By | Business Fraud, Business Litigation, Qui Tam Litigation

The Massachusetts Attorney General announced on December 11, 2018 that Target Corp. has agreed to pay $3 million to resolve allegations that it violated federal and state law by improperly billing and receiving payments from the Massachusetts’ Medicaid program (MassHealth).

Under the terms of the settlement, Target Corp. will pay $3 million to resolve allegations that from August 2009 through July 2015, the company operated an unauthorized automatic refill program at their Massachusetts locations.

Current regulations prohibit pharmacies in Massachusetts from automatically refilling prescriptions that were not explicitly requested by a MassHealth patient or caregiver at the time of each filling event. The AG’s Office alleges that Target automatically refilled prescriptions and billed MassHealth inappropriately for them: “Target did not follow state and federal regulations put place to prevent waste in our MassHealth system. This settlement will bring money back to our state and will help ensure that our health care resources reach those who need them the most.”

The AG’s Office has previously taken action against pharmacies for using improper automatic refill programs for MassHealth members. In August, PharmaHealth agreed to pay $360,000 to settle allegations of operating an unauthorized automatic refill program. In 2015, Neighborhood Diabetes paid $1.5 million to resolve allegations of improper billing and in 2013, AllCare Pharmacy paid $1.6 million to settle with the AG’s Office to resolve similar allegations.

The investigation stemmed from a qui tam action brought by a whistleblower in the United States District Court for the District of Minnesota. The qui tam action alleged claims under the federal False Claims Act and the Massachusetts False Claims Act.

If you have information regarding false claims having been submitted to the federal government and the information is not publically known and no actions have been taken by the government with regard to recovering the false claims, you should promptly consult with a False Claims Act attorney (also known as qui tam attorneys) in your U.S. state who may investigate the basis of your False Claims Act allegations and who may also assist you in bringing a qui tam lawsuit on behalf of the United States, if appropriate, for which you may be entitled to receive a portion of the recovery received by the U.S. government.

Email us at info@businesslitigationcontingencylawyers.com or telephone us toll-free in the United States at 800-756-2143 to to be connected with qui tam lawyers (False Claims Act lawyers) in your U.S. state who may assist you with a False Claims Act lawsuit.

BusinessLitigationContingencyLawyers.com – The Practical Solution For Business Litigation

Defense Contractor Pleads Guilty To Major Fraud In Provision Of Supplies To U.S. Troops In Afghanistan

By | Business Fraud, Business Litigation, Qui Tam Litigation

The U.S. Department of Justice announced on December 8, 2014 that Supreme Foodservice GmbH, a privately held Swiss company, and Supreme Foodservice FZE, a privately-held United Arab Emirates (UAE) company, pleaded guilty to major fraud against the United States and agreed to resolve civil violations of the False Claims Act, in connection with a contract to provide food and water to the U.S. troops serving in Afghanistan. The companies pleaded guilty in the Eastern District of Pennsylvania (EDPA) and paid $288.36 million in the criminal case, a sum that includes the maximum criminal fine allowed.

In addition, Supreme Group B.V. and several of its subsidiaries agreed to pay an additional $146 million to resolve a related civil lawsuit, as well as two separate civil matters, alleging false billings to the Department of Defense (DoD) for fuel and transporting cargo to American soldiers in Afghanistan.  The lawsuit was filed in the EDPA, and the fuel and transportation allegations were investigated by the Southern District of Illinois and the Eastern District of Virginia, respectively, along with the Department’s Civil Division.

According to court documents, between July 2005 and April 2009, Supreme Foodservice AG, together with Supreme Foodservice KG, now called Supreme Foodservice FZE, devised and implemented a scheme to overcharge the United States in order to make profits over and above those provided in the $8.8 billion subsistence prime vendor (SPV) contract.  The companies fraudulently inflated the price charged for local market ready goods (LMR) and bottled water sold to the United States under the SPV contract.  The Supreme companies did this by using a UAE company it controlled, Jamal Ahli Foods Co. LLC (JAFCO), as a middleman to mark up prices for fresh fruits and vegetables and other locally-produced products sold to the U.S. government, and to obscure the inflated price the Supreme companies were charging for bottled water.  The fraud resulted in a loss to the government of $48 million.

The government alleged that Supreme AG, Supreme FZE and Supreme’s owners made concentrated efforts to conceal Supreme’s true relationship with JAFCO, and to make JAFCO appear to be an independent company.  They also took steps to make JAFCO’s mark-up on LMR look legitimate, and persisted in the fraudulent mark-ups even in the face of questions from DSCP about the pricing of LMR.

Defendant Supreme GmbH pleaded guilty to major fraud against the United States, conspiracy to commit major fraud and wire fraud.  Supreme FZE, which owns JAFCO, pleaded guilty to major fraud against the United States.  The Supreme companies agreed to jointly pay $48 million in restitution and $10 million in criminal forfeiture.  Each company also agreed to pay $96 million in criminal fines.  In addition, as a result of the criminal investigation, the Supreme companies paid $38.3 million directly to the DSCP as a refund for separate overpayments on bottled water.

In a related civil settlement, Supreme Group agreed to pay another $101 million to settle a whistleblower lawsuit, filed in the U.S. District Court for the EDPA by a former executive, which alleged that Supreme Group, and its food subsidiaries, violated the False Claims Act by knowingly overcharging for supplying food and water under the SPV contract.  The payment also resolves claims that, from June 2005 to December 2010, the Supreme food companies failed to disclose and pass through to the government rebates and discounts it obtained from its suppliers, as required by its SPV contract with the United States.

Separately, Supreme Site Services GmbH, a Supreme Group subsidiary, agreed to pay $20 million to settle allegations that they overbilled for fuel purchased by the Defense Logistics Agency (DLA) for Kandahar Air Field (KAF) in Afghanistan under a NATO Basic Ordering Agreement.  The government alleged that Supreme Site Services’ drivers were stealing fuel destined for KAF generators while en route for which the company falsely billed DLA.

Supreme Group’s subsidiary Supreme Logistics FZE also has agreed to pay $25 million to resolve alleged false billings by Supreme Logistics in connection with shipping contracts between the U.S. Transportation Command (USTRANSCOM), located at Scott Air Force Base in Illinois, and various shipping carriers to transport food to U.S. troops in Afghanistan during Operation Enduring Freedom.  The shipping carriers transported cargo destined for U.S. troops from the United States to Latvia or other intermediate ports, and then arranged with logistics vendors, including Supreme Logistics, to carry the cargo the rest of the way to Afghanistan.  The United States alleged that Supreme Logistics falsely billed USTRANSCOM for higher-priced refrigerated trucks when it actually used lower-priced non-refrigerated trucks to transport the cargo.

The EDPA lawsuit was initially filed under the qui tam or whistleblower provisions of the False Claims Act, by Michael Epp, Supreme GmbH’s former Director, Commercial Division and Supply Chain.  The False Claims Act prohibits the submission of false claims for government money or property and allows the United States to recover treble damages and penalties for a violation.  Under the Act’s whistleblower provisions, a private party may file suit on behalf of the United States and share in any recovery.  The case remained under seal to permit the United States to investigate the allegations and decide whether to intervene and take over the case.  Epp will receive $16.16 million as his share of the government’s settlement of the lawsuit.

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If you have information regarding false claims having been submitted to the federal government and the information is not publically known and no actions have been taken by the government with regard to recovering the false claims, you should promptly consult with a False Claims Act attorney (also known as qui tam attorneys) in your U.S. state who may investigate the basis of your False Claims Act allegations and who may also assist you in bringing a qui tam lawsuit on behalf of the United States, if appropriate, for which you may be entitled to receive a portion of the recovery received by the U.S. government.

Email us at info@businesslitigationcontingencylawyers.com or telephone us toll-free in the United States at 800-756-2143 to to be connected with qui tam lawyers (False Claims Act lawyers) in your U.S. state who may assist you with a False Claims Act lawsuit.

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Actelion Pharmaceuticals Agrees To Pay $360 Million To Resolve False Claims Act Liability For Paying Kickbacks

By | Business Fraud, Business Litigation, Qui Tam Litigation

The U.S. Department of Justice announced on December 6, 2018 that Actelion Pharmaceuticals US, Inc. (“Actelion”) has agreed to pay $360 million to resolve claims that it illegally used a nonprofit foundation as a conduit to pay the copays of thousands of Medicare patients taking Actelion’s pulmonary arterial hypertension drugs, in violation of the False Claims Act.

Under the Anti-Kickback Statute, a pharmaceutical company is prohibited from offering or paying, directly or indirectly, any remuneration (which includes money or any other thing of value) to induce Medicare patients to purchase its drugs. This prohibition includes the payment of patients’ copay obligations.

When a Medicare beneficiary obtains a prescription drug covered by Medicare, the beneficiary may be required to make a partial payment, which may take the form of a copayment, coinsurance, or a deductible (“copays”). The U.S. Congress included copay requirements in the Medicare program, in part, to serve as a check on health care costs, including the prices that pharmaceutical manufacturers can demand for their drugs. The copay obligations can be substantial for expensive medications.

It was alleged by the federal government that Actelion used the foundation as an illegal conduit to pay the copay obligations of thousands of Medicare patients taking Actelion’s pulmonary arterial hypertension drugs, as an inducement for those patients to purchase its drugs because Actelion knew that the prices it set for those drugs could otherwise pose a barrier to those purchases.

The federal government claimed that from 2014 to 2015, Actelion made donations to the foundation, which, in turn, used those donations to pay copays of patients prescribed Actelion’s pulmonary arterial hypertension drugs. The federal government alleged that Actelion routinely obtained data from the foundation detailing how much the foundation had spent for patients on each such drug and then used this information to decide how much to donate to the foundation and to confirm that its contributions were sufficient to cover the copays of only patients taking its pulmonary arterial hypertension drugs. The foundation reportedly warned Actelion against receiving such data.

The federal government further alleged that Actelion had a policy of not permitting Medicare patients to participate in its free drug program, which was open to other financially needy patients, even if those Medicare patients could not afford their copays for its pulmonary arterial hypertension drugs. The federal government claimed that Actelion referred such Medicare patients to the foundation, which allowed the patients copays to be paid and resulted in claims to Medicare for the remaining cost, in order to generate revenue from Medicare and induce purchases of its pulmonary arterial hypertension drugs.

Actelion was acquired by Johnson & Johnson on June 16, 2017.

Source

If you have information regarding false claims having been submitted to Medicare, Medicaid, TRICARE, other federal health care programs, or to other federal agencies/programs, and the information is not publically known and no actions have been taken by the government with regard to recovering the false claims, you should promptly consult with a False Claims Act attorney (also known as qui tam attorneys) in your U.S. state who may investigate the basis of your False Claims Act allegations and who may also assist you in bringing a qui tam lawsuit on behalf of the United States, if appropriate, for which you may be entitled to receive a portion of the recovery received by the U.S. government.

Email us at info@businesslitigationcontingencylawyers.com or telephone us toll-free in the United States at 800-756-2143 to to be connected with qui tam lawyers (False Claims Act lawyers) in your U.S. state who may assist you with a False Claims Act lawsuit.

BusinessLitigationContingencyLawyers.com – The Practical Solution For Business Litigation

Federal Government Intervenes In Health Care Qui Tam Lawsuit

By | Business Fraud, Business Litigation, Qui Tam Litigation

The U.S. Department of Justice announced on December 11, 2018 that the United States has intervened in a complaint against Sutter Health LLC, a California-based healthcare services provider, and an affiliated entity, Palo Alto Medical Foundation, that alleges that Sutter violated the False Claims Act by submitting inaccurate information about the health status of beneficiaries enrolled in Medicare Advantage Plans.

Under Medicare Advantage, also known as the Medicare Part C program, Medicare beneficiaries have the option of enrolling in managed healthcare insurance plans called Medicare Advantage Plans (MA Plans) that are owned and operated by private Medicare Advantage Organizations (MAOs).  MA Plans are paid a capitated, or per-person, amount to provide Medicare-covered benefits to beneficiaries who enroll in one of their plans.

The Centers for Medicare and Medicaid Services (CMS), which oversees the Medicare program, adjusts the payments to MA Plans based on demographic information and the health status of each plan beneficiary.  The adjustments are commonly referred to as “risk scores.”  In general, a beneficiary with more severe diagnoses will have a higher risk score, and CMS will make a larger risk-adjusted payment to the MA Plan for that beneficiary.

Sutter Health, a non-profit public benefit corporation that provides healthcare services through affiliated entities, including hospitals and medical foundations, contracted with certain MAOs to provide healthcare services to California beneficiaries enrolled in the MAOs’ MA Plans.  In exchange, Sutter received a share of the payments that the MAOs received from CMS for the beneficiaries under Sutter’s care.

Sutter submitted diagnoses to the MAOs for the MA Plan enrollees that they treated.  The MAOs, in turn, submitted the diagnosis codes to CMS from the beneficiaries’ medical encounters, such as office visits and hospital stays, and these diagnosis codes were used by CMS to calculate a risk score for each beneficiary.

The False Claims Act lawsuit alleges that Sutter Health and Palo Alto Medical Foundation knowingly submitted unsupported diagnosis codes for certain patient encounters for beneficiaries under their care.  These unsupported diagnosis scores allegedly inflated the risk scores of these beneficiaries, resulting in inflated payments to Sutter.   The lawsuit further alleges that once the Sutter entities became aware of these unsupported diagnosis codes, they failed to take sufficient corrective action to identify and delete additional potentially unsupported diagnosis codes.

The lawsuit was filed under the qui tam, or whistleblowerprovisions of the False Claims Act, which permit private parties to sue on behalf of the government for false claims and to receive a share of any recovery.  The False Claims Act also permits the government to intervene in such lawsuits, as it has done in this case.  The whistleblower was a former employee of Palo Alto Medical Foundation.

The case is captioned United States ex rel. Ormsby v. Sutter Health, et al., Case No. 15-CV-01062-JD (N.D. Cal.).

Source

If you have information regarding false claims having been submitted to Medicare, Medicaid, TRICARE, other federal health care programs, or to other federal agencies/programs, and the information is not publically known and no actions have been taken by the government with regard to recovering the false claims, you should promptly consult with a False Claims Act attorney (also known as qui tam attorneys) in your U.S. state who may investigate the basis of your False Claims Act allegations and who may also assist you in bringing a qui tam lawsuit on behalf of the United States, if appropriate, for which you may be entitled to receive a portion of the recovery received by the U.S. government.

Email us at info@businesslitigationcontingencylawyers.com or telephone us toll-free in the United States at 800-756-2143 to to be connected with qui tam lawyers (False Claims Act lawyers) in your U.S. state who may assist you with a False Claims Act lawsuit.

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