The 10th Circuit Court of Appeals found that a doctor’s certification that a procedure was “reasonable and necessary” is false if the procedure doesn’t meet the government’s definition of what is reasonable and necessary, as determined by the Medicare Program Integrity Manual. Among the requirements is that the procedure is safe and effective; not experimental or investigational; and appropriate, including in duration and frequency. A doctor's subjective judgment as to "reasonable and necessary" was irrelevant.
Read more here: https://www.bna.com/medical-judgment-not-n73014477299/
According to the Department of Justice, the matter relates to the payment of kickbacks in return for referrals of patients to Pacific Hospital for spinal surgeries and other services, which were paid for primarily through the California workers' compensation system.
Read more here: http://www.healthcarefinancenews.com/news/more-doctors-indicted-15-year-long-580-million-kickback-scheme-pacific-hospital-long-beach.
More Than 600 Individuals Charged - Including 76 Doctors, 23 Pharmacists, and 19 Nurses - in $2 Billion Fraud Scheme
On June 28, 2018, the DOJ and HHA announced the largest ever health care fraud enforcement action involving 601 charged defendants across 58 federal districts, including 165 doctors, nurses and other licensed medical professionals, for their alleged participation in health care fraud schemes involving more than $2 billion in false billings. Of those charged, 162 defendants, including 76 doctors, were charged for their roles in prescribing and distributing opioids and other dangerous narcotics.
Read more here: https://www.justice.gov/opa/pr/national-health-care-fraud-takedown-results-charges-against-601-individuals-responsible-over.
In a recent False Claims Act intervenor complaint, the Department of Justice (DOJ) alleged that Riordan, Lewis & Haden (RLH), a private equity firm based in Los Angeles, participated in a scheme with Diabetic Care Rx to defraud the federal government's TRICARE program. RLH bought a controlling stake in Diabetic Care Rx in July 2012.
The case underscores the DOJ's willingness to hold private equity and other investment firms accountable for the compliance infractions of the organizations in which they invest.
Red more here: https://www.bna.com/private-equity-firms-n73014476196/
A federal judge has dismissed a False Claims Act case against Midwest-based Trilogy Health Systems involving allegations that Trilogy routinely administered unnecessary therapy to residents.
Read more here: https://www.mcknights.com/news/federal-judge-dismisses-therapy-whistleblower-case-allows-wrongful-firing-claim-to-continue/article/769600/
The owner of Redirections Treatment Advocates, LLC, an opioid addiction treatment organization with locations in Pennsylvania and West Virginia, has been indicted on charges of unlawfully dispensing controlled substances and health care fraud.
Read the DOJ's press release here: https://www.justice.gov/usao-wdpa/pr/redirections-treatment-owner-charged-unlawfully-distributing-buprenorphine-and.
Compliagent's CEO, Nick Merkin, Cited in Article About Contingency Planning Obligations Under the HIPAA Rules
Read the Full Article Here:
A proposed bill to create government price controls in California for surgeries, hospital stays, doctor visits and other health care services died when it failed to clear a key committee last week. Physicians, hospitals and other influential health care providers lobbied intensely against the bill, which they said would lead to longer waits for medical care.
Read more here: https://apnews.com/ebf4842b1e8546d99114287b4fbfe251/Bill-to-create-health-care-price-controls-in-California-dies
Five doctors from Redirections Treatment Advocates, LLC, an opioid addiction treatment practice in Pennsylvania and West Virginia, have been indicted on charges of illegally dispensing controlled substances and Medicare and Medicaid fraud.
Read more here: https://www.americanbar.org/groups/health_law/news/2018/05/five_physicians_from.html