HHS-OIG-Fraud Prevention & Detection - Enforcement Actions

Elmhurst Memorial Hospital ( Elmhurst), Illinois, agreed to pay $1,845 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that Elmhurst employed an individual that Elmhurst knew or should have known had been excluded from participation in Federal health care programs.

After it self-disclosed conduct to the OIG, Concord Extended Care and Care Centers, Inc. (collectively Care Centers), Illinois, agreed to pay $31,800 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that Care Centers employed an individual that Care Centers knew or should have known had been excluded from participation in Federal health care programs.

An owner of a DME company located in Massachusetts agreed to pay $13,700 to resolve her liability under the CMP provisions applicable to false and fraudulent claims. The OIG alleged that between April 1998 through January 2002 the owner submitted false claims to Medicare for power wheelchairs not provided to beneficiaries; failed to refund money to Medicare after beneficiaries returned the item(s); billed Medicare for electric wheelchairs, but provided beneficiaries with less expensive equipment; and billed Medicare for electric wheelchairs on particular dates of service, when, in fact, the wheelchairs were not provided until months after the dates of service. In addition, the owner and the DME company agreed to be permanently excluded from participation in Federal healthcare programs.

An individual who was a licensed paramedic and emergency medical technician (EMT) in Rhode Island, agreed to pay $20,000 to resolve his liability under the CMPL provisions applicable to false and fraudulent claims. The OIG alleged that the EMT caused the presentation of 2,115 claims to Medicare for the transportation of two Medicare beneficiaries that he knew or should have known were false or fraudulent and/or were for a pattern of services that were not medically necessary. Specifically, the OIG alleged that the EMT transported the two beneficiaries for routine dialysis treatments between their respective homes and a dialysis center.

After it self-disclosed conduct to the OIG, Rochester District Visiting Nurse Association (VNA), New Hampshire, agreed to pay $67,627.32 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that VNA employed an individual that VNA knew or should have known had been excluded from participation in Federal health care programs. As part of the agreement, VNA is required to submit to the OIG an annual certification for three years attesting that they have in place a policy for screening all current and prospective employees and contractors to ensure that they are not excluded.

An anesthesiologist who performs pain-management services in Oregon agreed to pay $50,000 and to enter into a five-year integrity agreement to resolve his liability under the CMPL provisions applicable to false and fraudulent claims. T he OIG alleged that the anesthesiologist caused Oregon Anesthesiology Group, P.C. (OAG) to submit false claims to Medicare and Medicaid by billing time for pre-operative patient evaluations even though the service was already included within the scope of the basic value unit used for reimbursement and for billing for pain management services for patients while simultaneously billing for preoperative anesthesia services for separate patients awaiting surgery. OAG settled its liability under the CMPL with the OIG on June 27, 2005 for $130,000.

University of Medicine and Dentistry of New Jersey (UMDNJ), New Jersey, agreed to pay $2 million to resolve its liability under the CMPL provisions applicable to false and fraudulent claims. The OIG alleged that UMDNJ employed two individuals that UMDNJ knew or should have known had been excluded from participation in Federal health care programs. As part of the agreement, UMDNJ is required to submit to the OIG an annual certification for three years attesting that they have in place a policy for screening all current and prospective employees and contractors to ensure that they are not excluded.

An owner of a DME company located in Colorado agreed to pay $100,000 to resolve her liability under the CMPL provisions applicable to false and fraudulent claims. The OIG alleged that the owner continued to bill the Medicaid program after she was excluded for ten years from participating in Federal healthcare programs. As a result, the OIG permanently excluded her from participating in Federal healthcare programs.

Cedar Oaks Care Center, Inc. (Cedar Oaks), New Jersey, agreed to pay $92,232.74 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that Cedar Oaks employed an individual that Cedar Oaks knew or should have known had been excluded from participation in Federal health care programs.

After it self-disclosed conduct to the OIG, Families First of the Greater Seacoast, Inc. (Families First), New Hampshire, agreed to pay $29,342.61 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that Families First employed a nurse that Families First knew or should have known was excluded from participation in Federal health care programs.

After it self-disclosed conduct to the OIG, Oregon Anesthesiology Group, P.C. (OAG), Oregon, agreed to pay $130,000 and to enter into a 3-year integrity agreement to resolve its liability under the CMP provisions applicable to false and fraudulent claims. The OIG alleged that from April 1, 1998 through March 31, 2003, OAG submitted false claims by billing time for pre-operative patient evaluations even though the service was already included within the scope of the basic value unit used for reimbursement. In addition, the OIG alleged that OAG submitted false claims by billing for pain management services for patients while simultaneously billing for pre-operative anesthesia services for separate patients awaiting surgery.

MedStar Health Visiting Nurse Association, Inc., formerly known as The Visiting Nurse Association of Washington, D.C., and its home office, Visiting Nurse Association, Inc., (collectively "MedStar VNA"), agreed to pay $1,360,000 and enter into a 5-year corporate integrity agreement to resolve their liability under the CMPL. The OIG alleged that MedStar VNA submitted cost reports to the Medicare program for fiscal years ending 6/30/98, 6/30/99, and 6/30/00 that contained claims that were false or fraudulent or that were not provided as claimed. In particular, the OIG's investigation focused on four basic fraud allegations that MedStar VNA failed to disclose certain costs or provide documentation associated with related third parties in the cost reports at issue. The settlement agreement also included the resolution of non-fraudulent adjustments that had resulted in an outstanding overpayment owed to the Medicare fiscal intermediary for the fiscal year 6/30/00 cost report.

(Note: This is a decision with a finding - not a settlement) An Administrative Law Judge issued a decision imposing CMPs and an assessment of $711,212 and a seven-year exclusion against Thomas Horras, the former president of Hawkeye Health Services, Inc. (Hawkeye), which was purchased by Auxi Health, Inc. (see the summary of 11/3/03 settlement below). The ALJ also imposed CMPs and an assessment of $4,646 and a one-year exclusion against Christine Richards, the former Director of Finance of Hawkeye. The ALJ held that Mr. Horras knowingly included 178 claims on cost reports submitted to Medicare and Medicaid from 1995 through 1997 that were for medical items or services that he knew or should have known were false or fraudulent, or not provided as claimed. Some of the claims were for unallowable costs associated with Mr. Horras’s own personal expenses that were not related to patient care and/or were not reasonable costs of the operation of Hawkeye. With respect to Christine Richards, the ALJ found that Ms. Richards acted with reckless disregard to the submission of 112 claims on the cost reports that were for medical items or services that were false or fraudulent, or not provided as claimed. On August 7, 2007, the United States Court of Appeals for the Eighth Circuit issued a decision affirming the decisions by the Departmental Appeals Board and Administrative Law Judge.

Ambulance Transportation Services, LLC (ATS), Texas, agreed to pay $154,029 and to enter into a 5-year integrity agreement to resolve its liability under the CMP provisions applicable to false and fraudulent claims. The OIG alleged that from May 11, 2002 through January 17, 2003, ATS submitted claims for services for which ATS had already received reimbursement. The alleged duplicate claims contained a different code that was reimbursed at a slightly higher rate than the code on the original claims.

A Virginia physician agreed to pay $45,644 to resolve his liability under the Civil Monetary Penalties Law. The OIG alleged that the physician violated the terms of his exclusion. In October 1994, the physician was excluded from participating in Federal health care programs for 10 years based on a program-related criminal conviction. In February 2000, the OIG alleged that the physician sought and received employment at a small chain of mental health facilities where he served as the medical director for two of the mental health facilities during February 2000 through July 2002. In addition to the settlement agreement, the physician will remain excluded for an additional three years.

A former Chief Executive Officer (CEO) of Good Samaritan Hospital, Nebraska, agreed to pay $130,000 and to enter into a 3-year integrity agreement to resolve his liability under the CMP provisions applicable to kickbacks. The OIG alleged that from September 1994 through October 1999, the former CEO provided financial assistance to a physician in the form of bank loan guarantees, the payment of consultant fees, and the provision of discounted pharmaceuticals, biologicals, supplies, and medical equipment to induce her referral of Medicare beneficiaries requiring cardiology care to the hospital. As a result of the former CEO’s conduct, he allegedly received annual bonuses that reflected, in part, the referrals made by the physician to Good Samaritan Hospital. The hospital previously entered into a False Claims Act settlement related to this conduct.

Home Health Corporation of America (HHCA), Pennsylvania, agreed to pay $300,000 and to enter into a 5-year integrity agreement to resolve its liability under the CMP provisions applicable to kickbacks. The OIG alleged that from February 1997 through May 1998, HHCA made payments in the form of loans, consulting fees, and monthly space rental payments to six physicians located in Pennsylvania and Florida to induce their referral of Medicare beneficiaries requiring home health services and/or durable medical equipment that was provided by HHCA and paid for by the Medicare program.

After it self-disclosed conduct to the OIG, St. Joseph Mercy-Oakland (SJMO), Michigan, agreed to pay $4 million to resolve its liability under the CMP provisions applicable to kickbacks and stark law violations. The OIG alleged that SJMO entered into financial arrangements with 14 different physicians and physician groups. The financial arrangements allegedly included office management services, medical equipment, lease and/or purchase agreements, loans, and income guarantees.