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Archives - False and Fraudulent Claims

In each CMP case resolved through a settlement agreement, the settling party has contested the OIG's allegations and denied any liability. No CMP judgment or finding of liability has been made against the settling party.

2007

11-28-2007
After it self-disclosed conduct to the OIG, Walgreen Home Care, Inc., Texas, agreed to pay $54,115 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that certain Walgreen employees altered information on Certificates of Medical Necessity (CMNs) that were used to support claims to the Medicare program by adding information that a patient's physician had failed to provide or adding physician signatures to unsigned CMNs.
09-20-2007
Dale Theberge and Aquatic Therapy of New England (ATNE), Massachusetts, agreed to pay $398,357.49 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that Theberge, on behalf of her physical therapy company, ATNE, (1) submitted false or fraudulent claims for physical therapy services when there was no licensed physical therapist working for ATNE during an approximately two month period in 2003, and (2) submitted upcoded claims for individual physical therapy services under incorrect CPT codes when instead, those claims should have been submitted under a specific group therapy CPT code.
09-18-2007
After it self-disclosed conduct to the OIG, Promesa, Inc. and Promesa Residential Health Care Facility, Inc. (collectively Promesa), New York, agreed to pay $1 million and to enter into a 3-year certification of compliance agreement for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that Promesa employed an individual that Promesa knew or should have known had been excluded from participation in Federal health care programs.
08-21-2007
After it self-disclosed conduct to the OIG, Trans Healthcare, Inc. (THI), Ohio, agreed to pay $137,454 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that THI's former CEO and CFO paid $48,500 in contributions to political candidates using company funds and then allocated $36,484 of the costs of the contributions across cost reports for various Medicaid funded facilities. THI is currently operating under a quality of care corporate integrity agreement.
04-30-2007
Ashland Nursing & Rehab, LLC d/b/a Ashland Healthcare (Ashland), Missouri, agreed to pay $87,857.68 and to enter into a 3-year certification agreement for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that Ashland employed an individual that Ashland knew or should have known had been excluded from participation in Federal health care programs.
03-27-2007
Kay Medical Services Corporation, Florida, agreed to pay $440,949 and agreed to be permanently excluded from participating in all Federal health care programs for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that Kay submitted claims that listed physicians as the referring physician for certain DME services that were not provided as claimed and were false and fraudulent.
01-19-2007
Midwest Medical Laboratory, Inc. (MML), Illinois, agreed to pay $711,157 and to a 5-year exclusion from participating in the Federal healthcare programs for allegedly violating the Civil Monetary Penalties Law (CMPL). Specifically, the OIG alleged that MML violated the CMPL when it submitted claims to Medicare Part B for payment for services rendered to beneficiaries who are residents of skilled nursing facilities (SNFs) in a stay covered by Medicare Part A. The OIG further alleged that the submission of these claims violated Medicare's consolidated billing requirements because an outside supplier may bill only the SNF, and not Medicare Part B, for services rendered to beneficiaries who are residents of SNFs in a covered Part A stay. The OIG also alleged that MML violated the CMPL when it submitted claims for the same service under both its Illinois and Florida provider numbers.
01-19-2007
After it self-disclosed conduct to the OIG, Innovative Pain Care, Inc. (IPC), Wisconsin, agreed to pay $45,264 for allegedly violating the Civil Monetary Penalties Law. Specifically, IPC disclosed to the OIG that a former IPC anesthesiologist and chronic pain physician billed Medicare for upcoded chronic pain procedures, evaluation and management office visits, and for chronic pain procedures not rendered.

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2006

12-19-2006
Cynthia Hawkinberry, an Ohio billing manager, agreed to be permanently excluded from participating in all Federal healthcare programs for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that Hawkinberry, who was previously excluded for 10 years caused claims to be submitted to Medicare for payment for services that she furnished during the period in which she was excluded from Medicare.
11-21-2006
Rosewood Cancer Center, Inc. (Rosewood), Jefferson Radiation Oncology Center Limited Partnership (JROC), Oaktree Cancer Center, Inc. d/b/a Greater Pittsburgh Cancer Center (Greater Pitt) and the owner of South Hills Radiation Oncology (South Hills), Pennsylvania, agreed to pay $155,000 to resolve their liability for billing Medicare for improper claims. South Hills had a contractual agreement to provide radiation oncology services to Rosewood, JROC, and Greater Pitt. The OIG alleged that the owner of South Hills caused JROC and Greater Pitt to present claims for reimbursement to Medicare for radiation oncology treatments that were provided at the JROC and Greater Pitt facilities without the presence of a physician on-site. In addition to the settlement agreement, the owner of South Hills agreed to enter into a 3-year integrity agreement.
07-10-2006
Athena Health Care Associates, Inc. (Athena), a nursing home management company located in Connecticut, agreed to enter into a corporate integrity agreement to resolve its liability under the CMP provisions applicable to false and fraudulent claims. The OIG alleged that Athena furnished or caused to be furnished care of a quality that failed to meet professionally recognized standards of health care to a number of Medicare and Medicaid beneficiaries at Hillcrest Healthcare Center (Hillcrest). Hillcrest previously had pled nolo contendere in to one count of manslaughter in the second degree for its role in the death of one Medicare beneficiary.
06-19-2006
An owner of a dialysis facility located in South Dakota agreed to pay $150,000 to resolve his liability for submitting or causing to be submitted, claims for payment to Medicare for inadequate and/or worthless services that were rendered to patients of his dialysis center during the period of October 2001 through August 2002. The OIG alleged that the owner was responsible for poor care that may have contributed to seven deaths that occurred over a six-month period during the first half of 2002. In addition, the owner failed to correct problems in staffing and management that he knew or should have known was causing the delivery of substandard care to patients. Specifically, the owner hired a nurse manager who he knew or should have known was unqualified to treat dialysis patients and manage a dialysis facility. The nurse manager allegedly failed to monitor and treat patients appropriately, and falsified patient records to cover her mistakes.
03-16-2006
MetroHealth System, Ohio, resolved a self-disclosure by refunding to the Government $43,324.90 in connection with claims it submitted to Medicare and the Ohio Department of Jobs and Family Services for services provided by an excluded nurse.
01-20, 2006

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.
01-13, 2006
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.
01-05-2006
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.

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2005

12-29-2005
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.
12-28-2005
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.
12-23-2005
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.
12-23-2005
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.
12-13-2005
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.
11-28-2005
An unlicensed psychologist located in Colorado agreed to pay $25,000 to resolve his liability under the CMPL provisions applicable to false and fraudulent claims. The OIG alleged that the unlicensed psychologist submitted claims for psychiatric services that were not provided as claimed and/or were false and fraudulent. Specifically, the OIG alleged that between 1999 and 2002, the unlicensed psychologist used the name and provider number of another licensed psychiatrist that he was working with to bill Medicare for services that he provided. As part of the settlement agreement, the unlicensed psychologist also agreed to be excluded from participation in Federal healthcare programs for three years.
11-03-2005
After it self-disclosed conduct to the OIG, Senior Living Properties, LLC, (SLP) d/b/a Garden Terrace Healthcare Center (Garden Terrace), Texas, agreed to pay $18,000 to resolve its liability under the CMP provisions applicable to false and fraudulent claims. The OIG alleged that SLP submitted claims for reimbursement for restorative case services prescribed for certain residents of Garden Terrace by a restorative aide that were not provided as claimed.
10-18-2005
After it self-disclosed conduct to the OIG, Yuma District Hospital ( Yuma), Colorado, agreed to pay $35,760 to resolve its liability under the CMP provisions applicable to false and fraudulent claims. The OIG alleged that Yuma submitted improper claims to Medicare and Medicaid for resident services supervised by teaching physicians without appropriate documentation of teaching physician supervision.
10-14-2005
An individual practitioner located in Iowa agreed to pay $47,717 and to a seven-year exclusion to resolve his liability under the CMP provisions applicable to false and fraudulent claims. The OIG alleged that during August 2000 through November 2004, the practitioner submitted claims for chiropractic services that were not provided as claimed.
09-09-2005
After it self-disclosed conduct to the OIG, College Hospital Anaheim PHP Program ( Anaheim), California, agreed to pay $149,216 and to enter into a certification of compliance agreement to resolve its liability under the CMP provisions applicable to false and fraudulent claims. The OIG alleged that from January 2004 through May 2004, Anaheim submitted improper claims to Medicare by providing false information regarding group therapy services for Medicare beneficiaries who either did not attend group therapy sessions or did not derive any benefit from the services because they did not actively participate.
08-12-2005
A former co-owner and Chief Financial Officer (CFO) of two home health agencies located in Wyoming agreed to pay $20,000 and to a permanent exclusion to resolve his liability under the CMP provisions applicable to false and fraudulent claims. The OIG alleged that the former CFO submitted claims for his salary as CFO in cost reports from 1994 through 1998, when at the time, he was otherwise employed as a full-time electrician or as a full-time real estate agent.
07-20-2005
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.
07-08-2005
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.
06-27-2005
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.
06-06-2005
After it self-disclosed conduct to the OIG, Methodist Sugar Land Hospital (Methodist), Texas, agreed to pay $16,080.58 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that Methodist employed a nurse that Methodist knew or should have known was excluded from participation in Federal health care programs.
05-09-2005
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.
05-5-2005
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.
04-28-2005
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.
04-12-2005
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.
02-02-2005
Lansing Surgery Center (LSC), a freestanding surgery clinic located in Michigan, agreed to pay $76,082 and to enter into a three-year corporate integrity agreement to resolve its liability under the CMP provisions applicable to false and fraudulent claims. The OIG alleged that a staff physician employed by LSC submitted improper claims to Medicare and Medicaid for payment for pain management services.

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2004

12-01-2004
After it self-disclosed conduct to the OIG, Gambro Healthcare, Inc. (Gambro), Colorado, agreed to pay $346,000 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that Gambro employed individuals that Gambro knew or should have known were excluded from participation in Federal health care programs.
08-27-2004
An administrative decision finding liability and imposing sanctions (not a settlement agreement). An Administrative Law Judge (ALJ) issued a decision imposing CMPs of $126,000 and a seven-year exclusion against Thomas O'Connor, M.D., of Wisconsin. The decision held that Dr. O'Connor submitted 126 false claims to the Medicare program seeking reimbursement for an expensive nuclear medicine test when, in fact, Dr. O'Connor knew or should have known that he had provided only a simple, inexpensive spirometry test. The ALJ also held that of the 126 claims submitted, 111 of them were not medically necessary. Dr. O'Connor appealed to the appellate division of the Department of Appeals Board (DAB), however, the DAB declined to review the ALJ decision.
06-24-2004
Wadley Ambulance Service (WAS), Oklahoma, agreed to pay $28,322 to resolve its liability under the CMP provisions applicable to false or fraudulent claims. The OIG alleged that WAS employed an individual that WAS knew or should have known had been excluded from participation in Federal health care programs.
06-03-2004
A Michigan physician agreed to pay $3,083.94 to resolve his liability under the CMP provisions applicable to false or fraudulent claims. The OIG alleged that the physician knowingly submitted to the Medicare program claims for physician services that were furnished by his son who was not a licensed physician.
06-03-2004
After it self-disclosed conduct to the OIG, St. Luke's Quakertown Hospital (St. Luke's), Pennsylvania agreed to pay $61,699 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that St. Luke's employed a RN that was excluded from participating in Federal health care programs.
04-19-2004
After it self-disclosed conduct to the OIG, Inova Health System (Inova), Virginia, agreed to pay $125,494 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that Inova employed two individuals and contracted with a physician that were excluded from participating in Federal health care programs.
02-11-2004
After it self-disclosed conduct to the OIG, St. Francis Hospital, Inc., a South Carolina hospital that provides home health, durable medical equipment, and hospice services agreed to pay $9,491,191 to resolve its liability under the CMP provisions applicable to false or fraudulent claims. The OIG alleged that the hospital inappropriately billed the federal health care programs for home health visits, durable medical equipment, and hospice care. The OIG alleged that claims were improper because visits were not documented, the need for skilled nursing care was not documented, supplies were billed when they were not ordered or documented, visits to patients were inconsistent with physicians' orders, physician signatures had not been obtained on certifications and plans of care, verbal orders were not properly documented, homebound status was not consistently documented, physician signatures were not obtained on certifications and recertifications, medications and supplies were not ordered or documented, certificates of medical necessity were incomplete or otherwise defective, and the provision of oxygen was inconsistent with physicians' orders.

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2003

12-16-2003
After it self-disclosed conduct to the OIG, Lexington Medical Center (LMC), South Carolina, agreed to pay $99,447 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that LMC employed two individuals that were excluded from participating in Federal health care programs.
12-05-2003
After it self-disclosed conduct to the OIG, Community Residences, Inc., Virginia, agreed to pay $25,403 for allegedly violating the Civil Monetary Penalties Law. The OIG alleged that CRI employed a physician who was excluded from participating in Federal health care programs as a medical director of two of CRI's facilities.
11-03-2003
Auxi Health Inc. (Auxi), Iowa, agreed to pay $125,000 to resolve its liability under the CMP provisions applicable to false or fraudulent claims. Auxi purchased Hawkeye Health Services, Inc. (Hawkeye), a home health agency, through a stock sale. The OIG alleged that Hawkeye submitted claims to the Federal health care programs for payment of items and services that were unrelated to patient care, such as professional fees for a business valuation of Hawkeye used in a divorce proceeding, advertising costs designed to increase patient utilization of Hawkeye's services, costs related to personal use of Hawkeye automobiles and the luxury portion of those automobiles, monthly membership dues to a social club, costs for pest control services at a personal residence, charitable donations, and costs related to the sale of Hawkeye.
04-22-2003
After it self-disclosed conduct to the OIG, Sacramento Center for Hematology and Medical Oncology (SCHMO), California, agreed to pay $15,000 to resolve its liability under the CMP provisions applicable to false or fraudulent claims. The OIG alleged that SCHMO administered certain tests outside SCHMO's offices yet billed Medicare as if the services were performed at the office of an SCHMO physician.
03-07-2003
After he self-disclosed conduct to the OIG, a Florida physician agreed to pay $61,795 to resolve his liability under the CMP provisions applicable to false or fraudulent claims for allegedly causing false claims to be submitted to Medicare using his provider number. For a five-month period, the physician worked at a clinic owned and operated by two individuals who allegedly obtained provider numbers from physicians working at their clinic and used the numbers to submit false claims to Medicare for laboratory and other services not rendered. The physician is no longer associated with the clinic.
03-03-2003
Sebasticook Valley Hospital, Maine, agreed to pay $25,000 to resolve its liability under the CMP provisions applicable to false or fraudulent claims and patient dumping violations. The OIG alleged that the hospital submitted a false document as an exhibit in support of a cost report appeal. The OIG also alleged that the hospital failed to ensure a safe and appropriate transfer of a woman with post-partum active bleeding and failed to perform an appropriate medical screening examination of a 19-year-old pregnant woman to determine if the patient had an emergency medical condition.

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