Literature Review

DOJ slaps $20M opioid prescription penalty on OptumRx Fierce Healthcare; by Noah Tong; 7/2/24 OptumRx will pay $20 million to resolve claims the company violated the Controlled Substances Act by improperly filling certain opioid prescriptions, the Department of Justice recently announced. The agency claims OptumRx did not fill prescriptions correctly for "trinity prescriptions" like benzodiazepines and other muscle relaxants from April 2013 to April 2015. These prescriptions, which are addictive, may not have been “intended for legitimate medical use” and carry “significant risk of harm,” according to a news release. “Pharmacies providing opioids and other controlled substances have a duty under the Controlled Substances Act to ensure that they fill prescriptions only for legitimate medical purposes,” said Principal Deputy Attorney General Brian Boynton, head of the Justice Department’s Civil Division, in a statement. “The department will continue to work with its law enforcement partners to ensure that pharmacies do not contribute to the opioid addiction crisis.”

National Health Care Fraud Enforcement Action results in 193 defendants charged and over $2.75 billion in false claims United States Attorney's Office - Western District of Virginia, Charlottesville, VA; 6/27/24 The Justice Department today announced the 2024 National Health Care Fraud Enforcement Action, which resulted in criminal charges against 193 defendants, including 76 doctors, nurse practitioners, and other licensed medical professionals in 32 federal districts across the United States, for their alleged participation in various health care fraud schemes involving approximately $2.75 billion in intended losses and $1.6 billion in actual losses. In connection with the coordinated nationwide law enforcement action, and together with federal and state law enforcement partners, the government seized over $231 million in cash, luxury vehicles, gold, and other assets. 

Tapestry Hospice settles healthcare kickback claims for $1.4 million United States Attorney's Office - Northern District of Georgia; Press Release; 6/20/24 Tapestry Hospice of Northwest Georgia, LLC, and its owners and managers, David Lovell, MD, Stephanie Harbour, Ben Harbour, and Andrew Nall (collectively “Tapestry”), agreed to pay $1.4 million to resolve allegations that they violated the False Claims Act by entering into kickback arrangements with medical directors in exchange for referrals of hospice patients to Tapestry. “By entering into kickback arrangements, health care providers can cause doctors to make medical decisions that are motivated by financial gain, rather than the patient’s best interest,” said U.S. Attorney Ryan K. Buchanan. “Our office is committed to ensuring the accountability of health care providers who put their own financial needs ahead of their patients.” “The False Claims Act settlement in this case will hopefully be a deterrent to those who selfishly evade our federal healthcare programs for their own benefit,” said Keri Farley, Special Agent in Charge of FBI Atlanta. “The message is clear, the FBI will not tolerate companies operating corporate-wide schemes to illegally line their pockets.” 

Sens. Warren, Markey propose bill that would lead to prison time for 'corporate greed' in health careFox News [reported by KFF Health News]; by Landon Mion; 6/12/24The Corporate Crimes Against Health Care Act would create a new criminal penalty that could land executives in prison for up to six years. Massachusetts Sens. Elizabeth Warren and Ed Markey, both Democrats, introduced legislation Tuesday that would result in prison time for violators of "corporate greed" in health care. The Corporate Crimes Against Health Care Act would also offer state attorneys general and the U.S. Justice Department more tools to go after health care executives accused of corporate exploitation for endangering patient safety and access to health care, according to a press release.

Care provider to pay $14.9M over false claims involving assisted living communitiesMcKnight's Senior Living; Kimberly Bonvissuto; 6/10/24A chronic disease management provider will have to shell out $14.9 million over allegations related to false claims involving assisted living communities, memory care communities and group homes. Bluestone Physician Services of Florida LLC, Bluestone Physician Services PA of Minnesota and Bluestone National LLC of Wisconsin agreed to a $14.9 million settlement with the Justice Department. The federal government alleged that Bluestone knowingly submitted false claims to Medicare, Medicaid and TRICARE — the healthcare program for active duty service members and their families — for certain evaluation and management codes for services related to chronic care management of assisted living residents. The settlement agreement resolves allegations that Bluestone submitted “inflated” claims between Jan. 1, 2015, and Dec. 31, 2019, that did not support the level of service provided. The federal government will receive $13.8 million from the settlement, with more than $1 million going to the states of Florida and Minnesota.

Five arrested over 'sham hospices' alleged to bilk Medicare for over $15 million Los Angeles Times; by Emily Alpert Reyes; 6/8/24 Angeles over an alleged scheme to bilk the Medicare program of more than $15 million. The U.S. Department of Justice said three of the San Fernando Valley residents who were arrested — Petros Fichidzhyan, also known as Peter; Juan Carlos Esparza; and Karpis Srapyan, also known as Tony Levy — were accused of running "sham hospice companies" and turning in fraudulent claims to Medicare for hospice services. ... As part of the alleged scheme, the three defendants misappropriated the identifying information of doctors to claim those physicians had deemed hospice services necessary for patients, federal prosecutors said. They also allegedly used the names and Social Security numbers of Russian and Ukrainian citizens who had left the U.S. to open bank accounts and sign leases, indicating that the "impersonated identities" were the owners of the hospice companies that they in fact controlled, according to the federal indictment. 

Kickbacks and medically unnecessary treatments: Five major qui tam settlements from May 2024 JD Supra; by Geoff Schweller; 6/5/24 Under the FCA’s qui tam provisions, a crucial tool in combating healthcare fraud, whistleblowers have the power to file suits on behalf of the federal government if they possess the knowledge of an individual or company defrauding the government. The government may choose to intervene and take over the suit, but if a qui tam lawsuit results in a successful settlement, the whistleblower is eligible to receive between 15-30% of the monies collected. The settlements announced in May cover a wide range of alleged misconduct that violates the FCA, including cases concerning kickbacks and the billing of federal healthcare programs for medically unnecessary treatments. Each settlement represents a victory in the ongoing battle against fraud. ... [Non-hospice examples followed by this hospice case] $4.2 Million Settlement with Elara Claring for Allegedly Billing Medicare for Ineligible Hospice Patients ...

Joel Mekler - Medicare Moments: Watch out for these latest scams New Castle News; by Joel Mekler; 6/3/24 ... Across the country, many unscrupulous hospice providers are recruiting and enrolling nonterminally ill patients for end-of-life care they do not need and then billing Medicare for services and items they may never receive. They trick beneficiaries into signing up for hospice by offering freebies, such as additional groceries, nurse visits, durable medical equipment, bus coupons, and more once they enroll. They also make false claims, such as saying “Medicare now covers cooking and cleaning services”. Or they tell beneficiaries they qualify due to age, saying “You’re now old enough to qualify for hospice!” Another tactic is giving money, with some recruiters telling beneficiaries, “You can earn $400/month if you agree to enroll in our program.” ... Tips [to consumers] to avoid hospice fraud:

Hospice Owner Sentenced to 240 Months Imprisonment and Ordered to Repay $42,000,000 for Defrauding MedicareDepartment of Justice; 5/16/24New Orleans - U.S. Attorney Duane A. Evans announced that on May 15, 2024, U.S. District Judge Lance Africk sentenced SHIVA AKULA (“AKULA”), age 68, of New Orleans, to 240 months of imprisonment, three years of supervised release and $2,300 in mandatory special assessment fees, in relation to an extensive health care fraud scheme orchestrated by AKULA. In November 2023, a federal jury convicted AKULA of all 23 counts of his underlying indictment. AKULA owned and oversaw the day-to-day operations of Canon Healthcare, LLC, a hospice facility with offices in the New Orleans area, Baton Rouge, Covington, and Gulfport, Mississippi. At sentencing, the Court found that between January 2013 and December 2019, Canon billed Medicare approximately $84 million in fraudulent claims and was paid approximately $42 million relating to these fraudulent claims. The Court ordered that AKULA repay the $42 million of fraudulent proceeds back to Medicare.

Van Duyne, Blumenauer, 38 lawmakers push CMS on hospice integrityVanDuyne.house.gov; Press Release; 5/8/24Today, Congresswoman Beth Van Duyne (R-TX) and Congressman Earl Blumenauer (D-OR) led a bipartisan group of 38 lawmakers demanding answers from Centers for Medicare & Medicaid Services (CMS) on the implementation of recent reforms aimed at combatting hospice fraud and abuse. “When electing to receive hospice care, individuals and their families must be confident the provider is committed to delivering individualized, compassionate care that optimizes quality of life; however, we continue to hear about instances of pervasive fraud and abuse,” the lawmakers wrote.  ... To better understand the steps CMS has taken to increase program integrity, the lawmakers continued the letter with detailed questions on the implementation of reforms. Read the full letter here.  ...“Thank you, Representatives Blumenauer and Van Duyne, for your leadership in holding CMS accountable and safeguarding hospice patients and families from fraudulent activities,” said Ben Marcantonio, Interim CEO of the National Hospice and Palliative Care Organization. “Preserving the integrity of the Medicare Hospice Benefit is paramount to ensure high-quality care for Americans with serious illness and end-of-life care needs.” 

Fraudulent hospice providers may be moving between states Hospice News; by Jim Parker; 5/7/24Fraudulent hospices continue to proliferate, and some may be moving between states to escape regulators. Beginning in 2021, numerous reports emerged of unethical or illegal practices among hundreds of newly licensed hospices, particularly among new companies popping up in California, Texas, Nevada and Arizona. Thus far, California is the only state to take action on the issue, including a moratorium on hospice licensing. The U.S. Centers for Medicare & Medicaid Services has also taken steps to bolster program integrity.

[FL] Attorney General Moody announces arrest of two Seminole County residents for Medicaid fraud Office of Attorney General Ashley Moody [Florida]; by Kylie Mason; 4/23/24 Attorney General Ashley Moody’s Medicaid Fraud Control Unit, ... announced the arrest of Debora Behnke and Suman Bhattacharjee ...  [They] ran Pioneer Medical Transportation LLC and submitted fraudulent claims for nonemergency medical transportation for Medicaid recipients, stealing more than $250,000 from the Medicaid program.  "Instead of transporting vulnerable Medicaid recipients, these individuals falsely billed the taxpayer-funded program for services never completed. In some instances, they even convinced patients to move across the state—with no regard for the best interest of the patients—and still charged Medicaid for transporting them from the original, longer distance. ..."

Hospice fraud must be stopped!Hospice Action Network; via email; 4/26/24Across multiple states, the same story is playing out: Criminals are defrauding Medicare, getting licensed and certified to operate as hospices when they have no intent of providing care. This flagrant abuse of vulnerable patients and our healthcare system must be stopped in its tracks. We need your help! Ask your representatives to support a letter demanding answers from CMS. We need as many signatures as possible to keep the pressure on CMS.Take action today!