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Healthcare Fraud – False Certifications and False Information as Basis for Qui Tam Lawsuits

Health care providers who submit Medicare and Medicaid claims containing false statements also may be liable under the False Claims Act.

Examples

In Florida, five persons were involved in a scheme in which Medicare was fraudulently billed about $5.2 million for oxygen concentrators, nebulizers, medications and tests. Three men were ordered to pay $2.3 million in restitution, and were sentenced to 41, 46 and 51 months in jail, for paying physicians for prescriptions that they sold to two medical supply companies and a laboratory to use in billing Medicare. One of the company owners and one of the physicians who also had billed for house calls he did not make were convicted and given prison terms as well.

Employees of a New York pharmaceutical corporation were forging doctors' signatures on certificates of medical necessity and beneficiaries' signatures on assignment forms for surgical dressings. An investigation of the three subsidiaries, all of which were operated by the same corporate officer, showed the same activities for incontinence, ostomy and urostomy supplies. The companies also violated point-of-sale regulations and billed for supplies never sent. The company and its subsidiaries agreed to pay $3.4 million to settle government allegations that they filed false Medicare claims.

The owner/president of a Texas home health agency forged physicians' signatures on certification forms, and the controller directed employees to alter nurses' notes, add services to Medicare claims and use the forged forms. He also made false ledger entries and carried "ghost" employees on payroll records. The agency, its owner/president and its controller were sentenced to pay $1.3 million in fines, restitutions and special assessments for submitting false claims to Medicare.

The two principal executive officers of a home health services agency engaged in massive fraud by falsifying and altering training certificates and other credentials of personal care aides and home health care aides employed by the company. The two individuals and their corporation were excluded for 15 years from participation in Medicare and state health care. The corporation pled guilty to falsifying personnel files and grand larceny. It agreed to pay $4.75 million to resolve liabilities under the civil monetary penalties law, the False Claims Act and New York state statutes.

A Maryland durable medical equipment company submitted claims for more than a year for lymphedema pumps under a code for which the pumps did not meet specifications. It agreed to pay $1.5 million to resolve liabilities under the civil monetary penalties law.

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