Thursday, April 28, 2011

The "Craigslist doctor" gets flagged and goes to prison

The U.S. Attorney for New Jersey announced that Yousuf Masood, "a doctor with a practice in Elizabeth, N.J., and his wife pleaded guilty today to a health care fraud scheme in which more than 20,000 patient visits were conducted by individuals posing as licensed physicians for as little as $10 an hour . . . .  Yousuf Masood, 47, and his wife, Maruk Masood, of Warren, N.J., pleaded guilty today to separate Informations charging them each with one count of conspiracy to commit health care fraud.  The defendants entered their guilty pleas before U.S. Magistrate Judge Patty Shwartz in Newark federal court.  According to documents filed in this case and statements made in court:  Yousuf Masood admitted that he used unlicensed individuals to diagnose and treat patients in his Elizabeth office and billed Medicaid and Medicare as if he had provided the services. As part of his guilty plea, Yousuf Masood agreed to pay more than $1.8 million in restitution and forfeiture based on the fraudulent Medicaid and Medicare billings."

Wednesday, April 27, 2011

Stevens trial started today (Prosecutor tells jury: "A lawyer who went too far")

Pharmalot has an update on the Lauren Stevens trial:
After months of anticipation, the trial of former GlaxoSmithKline lawyer Lauren Stevens, who was indicted for last November for obstructing an FDA probe into off-label marketing of the Wellbutrin SR antidepressant and making false statements to the agency, has finally gotten under way. And in their opening remarks, federal prosecutors says she was a “lawyer who went too far.”
Click here for the rest of the story.

Tag and Release: Tracking doctors' movements at conferences

Dr. Wes Fisher is blogging that "a disturbing trend of monitoring physician quality and accountability has taken another ominous turn: tracking physician's movements at scientific conferences (so called "tag and release") using RFID tags . . . . (click here for the full post).

Tuesday, April 26, 2011

HHS's attempt to exclude Howard Solomon (Forest Labs) is sending shock waves in the industry

The WSJ is reporting that the
Government attempt to oust a longtime drug-company chief executive over his company's marketing violations is raising alarms in that industry and beyond about a potential expansion of federal involvement in the business world.
The Department of Health and Human Services this month notified Howard Solomon of Forest Laboratories Inc. that it intends to exclude him from doing business with the federal government. This, in turn, could prevent Forest from selling its drugs to Medicare, Medicaid and the Veterans Administration. If the government implements its ban, Forest would have to dump Mr. Solomon, now 83 years old, in order to protect its corporate revenue. No drug company, large or small, can afford to lose out on sales to the federal government, a major customer.
Click here for my earlier post.

Oral argument is today in Sorrell v. IMS Health

The Supreme Court will hear arguments in a case, Sorrell v. IMS Health, that tests whether Vermont’s prescription confidentiality law violates the free speech protections of the First Amendment.

Click here for an earlier post on the case.  Click here for a related post.

I’ll link to the audio recordings of the oral argument as soon as the SCOTUS posts them.

Here is how the New York Times sets up the case:

Before pharmaceutical company marketers call on a doctor, they do their homework. These salespeople typically pore over electronic profiles bought from data brokers, dossiers that detail the brands and amounts of drugs a particular doctor has prescribed. It is a marketing practice that some health care professionals have come to hate.  “It’s very powerful data and it’s easy to understand why drug companies want it,” said Dr. Norman S. Ward, a family physician in Burlington, Vt. “If they know the prescribing patterns of physicians, it could be very powerful information in trying to sway their behavior — like, why are you prescribing a lot of my competitor’s drug and not mine?”



Update on Community Health Systems (a qui tam case has been unsealed)

Healthcare Finance News is reporting that the "U.S Justice Department has broadened its probe of Community Health Systems’ outpatient billing practices, according to a company filing with the Securities and Exchange Commission.  Monday's filing from CHS, currently locked in a bitter hostile takeover attempt of Tenet Healthcare, comes in addition to a filing late Friday disclosing a two-year-old whistleblower (qui tam) lawsuit United States ex rel. Reuille vs. Community Health Systems Professional Services Corporation and Lutheran Musculosskeletal Center, LLC d/b/a Lutheran Hospital, filed in Indiana."

Click here for an earlier posting.

Below is the relator's recently unsealed complaint (note, the U.S. has not intervened).
Reuille Ex Rel. U.S. v. CHS Complaint)

HIV infusion fraud nets lengthy prison sentence

DoJ just announced that two "Miami-area medical assistants and a physician assistant were sentenced to prison today for their roles in a $23 million Medicare fraud scheme involving HIV infusion therapy, announced the Departments of Justice and Health and Human Services.   Jose Diaz, a 62-year old physician assistant, Lisandra Aguilera, a 40-year old medical assistant, and Estrella Rodriguez, a 43-year old medical assistant, were sentenced by U.S. District Judge Joan A. Lenard to 54 months, 70 months and 57 months in prison, respectively.   The defendants each previously pleaded guilty to one count of conspiracy to commit health care fraud for their roles in an HIV infusion fraud scheme."

LA scam artist shows how easy it is to set up fake clinics and pay off docs to scam Medicare

Businessweek is reporting that "Sherman Oaks resident Eduard Aslanyan, 37, admitted to establishing a series of fraudulent Los Angeles-area clinics to scam the federal medical health insurance provider between March 2007 and September 2008, according to a statement from the Department of Justice on Wednesday.  Aslanyan's complex scheme involved recruiting doctors to sign off on being medical directors for the fraudulent clinics and then recruiting Medicare beneficiaries whose billing information was used for expensive and medically-unnecessary wheelchairs and diagnostic tests, according to the statement."

Click here for the DoJ press release.

Thursday, April 21, 2011

Listen to this Man: Professor Sparrow's congressional testimony

Professor Sparrow (Harvard) is one of the few serious academics who has given meaningful thought to health care fraud.  It baffles me that health care fraud costs the country hundreds of billions of dollars yet our politicians devote more resources to the "War on Drugs" than on preventing, deterring, and prosecuting pharmaceutical fraud, which costs the country billions of dollars and harms patients. 

Below is Professor Sparrow's recent testimony to the U.S. Senate.  Here is an excerpt:  "The units of measure for losses due to health care fraud and abuse in this country are hundreds of billions of dollars per year.  We just don’t know the first digit.  It might be as low as one hundred billion. More likely two or three. Possibly four or five.  But whatever that first digit is, it has eleven zeroes after it.  These are staggering sums of money to waste, and the task of controlling and reducing these losses warrants a great deal of serious attention."

Testimony MKSparrow Senate Judiciary Committee Subcommittee on Crime & Drugs Health Care Fraud 5-20-2009

Wednesday, April 20, 2011

I'm currently reading Harvard Professor Malcolm Sparrow's License to Steal

If you really want to understand health care fraud and the problem it poses to America, then read Harvard Professor Malcolm Sparrow's License to Steal.

Click here for a link to learn more about the book and Professor Sparrow.

Click here for an Amazon link.


Tuesday, April 19, 2011

Finished reading: Side Effects by Allison Bass

I just finished reading Side Effects, A Prosecutor, a Whistleblower, and a Bestselling Antidepressant on Trial, by Allison Bass. 

Here is an Amazon link.

Click here for a link to a C-Span BookTV interview of Bass.

The WSJ reviewed the book: "Prozac improved the nation's mood when it came on the market in 1987. Earlier antidepressants had caused many side effects and were potentially lethal in overdose. Prozac appeared to be both a godsend and a blockbuster. It was effective, easy to administer and less likely to be used by depressed patients as a means to commit suicide. It was a boon to the bottom line of its manufacturer, Eli Lilly, but it also became a cautionary tale for the drug industry—of pharmaceutical success inspiring suspicion, controversy and backlash."  (Click here for the full review.)

Medicaid for the dead? It's Dia de los Medicaid Muertos in New Mexico.

HHS-OIG found that the New Mexico Medicaid program paid for services allegedly provided to dead people.  (It's Dia de los Medicaid Muertos in my second favorite state--click here to see why it's my second favorite state).  

See the report below. Here is an excerpt:  "The State agency made Medicaid payments for capitation and fee-for-service claims that followed recipients’ dates of death. Of the 2,122 claims we reviewed, the State agency paid $948,554 for 1,882 claims that were appropriate or identified as overpayments and the funds recovered. Of the remaining 240 claims, the State agency paid a total of $23,708 ($16,966 Federal share) for 53 claims for 11 deceased Medicaid recipients. We were not able to determine the death status of 18 recipients who had 187 claims totaling $105,229."
HHS-OIG Report (New Mexico Death Payments)

CVS Pharmacy Inc. Agrees to Pay $17.5 Million to Resolve False Prescription Billing Case

CVS Pharmacy Inc., the retail pharmacy division of CVS Caremark Corporation that operates more than 7,000 retail pharmacies in 41 states and the District of Columbia, has agreed to pay the United States and 10 states $17.5 million to resolve False Claims Act allegations, the Justice Department announced today. The settlement resolves allegations that CVS submitted inflated prescription claims to the government by billing the Medicaid programs in Alabama, California, Florida, Indiana, Massachusetts, Michigan, Minnesota, New Hampshire, Nevada and Rhode Island for more than what CVS was owed for prescription drugs dispensed to Medicaid beneficiaries who were also eligible for benefits under a primary third party insurance plan (excluding Medicare as the primary payor).   The United States alleged that rather than billing the government for what the insured would have been obligated to pay had the claims been submitted solely to the third party insurer (typically the co-pay), CVS billed and was paid a higher amount by Medicaid.

Monday, April 18, 2011

Forest Labs CEO fights back

I blogged a few days ago about how HHS-OIG is seeking to exclude Howard Solomon from federal health care programs.  

Mr. Solomon, however, is not going down without a fight.  Click here for a press release from the company; below is an excerpt.
"Forest Laboratories, Inc. (NYSE: FRX) today announced that Howard Solomon, Chairman, Chief Executive Officer and President, will challenge a potential action by the Office of the Inspector General, Department of Health and Human Services (HHS-OIG), to exclude him from participation in federal healthcare programs. Mr. Solomon was notified yesterday of the potential action in a letter from HHS-OIG."
Stay tuned . . . this will be interesting fight.  Click here and here for more.

Two Owners of Miami-Area Mental Health Care Corporation Plead Guilty to Orchestrating $200 Million Medicare Fraud Scheme

Two Miami-area residents and owners of a mental health care corporation, American Therapeutic Corporation (ATC), pleaded guilty today in U.S. District Court in Miami for orchestrating a fraud scheme that resulted in the submission of more than $200 million in fraudulent claims to Medicare, the Departments of Justice and Health and Human Services (HHS) announced.  Lawrence S. Duran, 49, and Marianella Valera, 40, pleaded guilty at an arraignment hearing before Magistrate Judge Barry L. Garber to all counts charged in a superseding indictment, which was unsealed on Feb. 15, 2011.   The superseding indictment charges Duran with 38 felony counts and Valera with 21 felony counts, including conspiracy to commit health care fraud, health care fraud, conspiracy to pay and receive illegal health care kickbacks, conspiracy to commit money laundering, money laundering and structuring to avoid reporting requirements.   The court must hold a hearing scheduled for a later date to accept and enter the guilty pleas.    

Washington State about to enact a False Claims Act

Virginia Qui Tam Blog has an update on the battle to enact a False Claims Act in the State of Washington.

Friday, April 15, 2011

Update on Former GSK Attorney Lauren Stevens (hearing today, trial set for April 26)

There will be a hearing today for the Court to address pre-trial matters.  Trial is tentatively set for April 26.  I won't be there but we'll attempt to have somebody live blogging the trial.

Here is the DoJ press release regarding the re-indictment of Stevens:
An attorney who formerly worked for a major pharmaceutical company was re-indicted on charges of obstruction and making false statements, the Justice Department announced today.   The new indictment identifies GlaxoSmithKline (GSK) as Lauren Stevens’ employer at the time of the alleged obstruction and false statements. GSK has not been charged with a crime.Stevens, a resident of Durham, N.C., is charged with one count of obstructing an official proceeding, one count of concealing and falsifying documents to influence a federal agency and four counts of making false statements to the Food and Drug Administration.   The indictment returned late Wednesday in the District of Maryland contains essentially the same charges that were brought against Stevens in November 2010.   On March 23, 2011, the original indictment was dismissed by the District Court Judge Roger W. Titus.   Judge Titus has scheduled a status conference for April 15, 2011, and set a tentative trial date of April 26, 2011.  Charges contained in the indictment are simply accusations, and not evidence of guilt.   Evidence supporting the charges must be presented to a federal trial jury, whose duty it is to determine guilt or innocence.

Forest CEO Faces Ban From Medicaid & Medicare

Click here for the story from Pharmalot.

Thursday, April 14, 2011

News Flash--DoJ re-indicts former GSK counsel Lauren Stevens

Financial Fraud Law is reporting that "Lauren Stevens, an attorney for a major pharmaceutical company, has been charged with obstruction and making false statements. In particular, Stevens was charged with one count of obstructing an official proceeding, one count of concealing and falsifying documents to influence a federal agency, and four counts of making false statements to the Food and Drug Administration (FDA)."

$27 Million in Medicare Shoe Fraud

U.S. Attorney James Santelle has reached a $27 million plea agreement with Rickey Kanter, former CEO of Rikco International in Mequon, resolving allegations of fraud against the Medicare program.  The agreement arose out of an investigation that Kanter, doing business as "Dr. Comfort," sold shoe inserts for diabetic patients that were falsely represented and marketed as conforming to Medicare's requirements for those products.  Many of those products were provided to beneficiaries of the Medicare program in 2004 and the inserts were reimbursed by Medicare. Despite being advised that the inserts did not conform to Medicare’s requirements, Kanter continued to sell the non-compliant inserts in 2006.  Pursuant to the plea agreement, Kanter has agreed to plead guilty to a felony charge of mail fraud. The government has agreed to recommend that Kanter be sentenced to 18 months in prison. Kanter is free to argue for a lower sentence. His sentence will be determined by a federal judge at a later date.  The whistle blowers, both former employees of Dr. Comfort, will receive payments totaling more than $4.8 million from the civil recovery.
Click here for a related story.

Houston RN Pleads Guilty ($5.2 Million Medicare fraud scheme--false enrollment)

A registered nurse employed by a Houston health care company pleaded guilty today in connection with an alleged $5.2 million Medicare fraud scheme, announced the Departments of Justice and Health and Human Services (HHS).
Adelma Casas Sevilla, 54, pleaded guilty before U.S. District Court Judge Nancy Atlas in Houston to one count of conspiracy to commit health care fraud.  According to court documents, Family Healthcare Group, a home health care company, purported to provide skilled nursing to Medicare beneficiaries.  According to court documents, Family Group hired co-conspirators to recruit Medicare beneficiaries for the purpose of filing claims with Medicare for skilled nursing that was medically unnecessary and/or not provided.  After the Medicare beneficiaries were recruited, Casas Sevilla, in her capacity as a registered nurse, fraudulently signed plans of care stating that the beneficiaries needed home health care when in fact she knew the beneficiaries were not home-bound and not in need of skilled nursing.
Comment:  "false enrollment" is one of easiest forms of health care fraud to commit.  The system merely relies upon the honesty of the provider who intakes the prospective "patient."  Most, but not, all providers are honest. 

Wednesday, April 13, 2011

Movement on disclosing Medicare payments to doctors

Momentum is starting to build on making Medicare payments to doctors public information.  

A Senate bill aimed at curtailing Medicare fraud would publish physician billing data online, letting viewers determine how much individual doctors earn annually from the program.  The release of the data has been prohibited by a court ruling for more than 30 years. But some lawmakers recently stepped up their efforts to lift the ban and bring Medicare billing data to light to prevent fraud.
Click here for a related WSJ article.

The Government spends over $1 Trillion on health care, about half of that ending up in the pockets of doctors.  The DoD budget, on the other hand, is about $550 Billion.  Yet it's easy to obtain information about DoD contractors.  See here and here.

Tuesday, April 12, 2011

Here are my slides and article for my presentation to the San Antonio Mexican-American Bar Association

Hargrove (MABA -- San Antonio Apr 2011)
SBOT (Hargrove - Article)

Look at who is blowing the whistle--Tenet accuses rival CHS of Medicare fraud

The AP is reporting that "Tenet Healthcare has charged rival hospital operator Community Health Systems with systematically bilking Medicare, and the burgeoning legal fight sent shares of the entire sector sliding Monday.  The charges come months after Community launched a $3 billion hostile takeover bid for Tenet. The Dallas company said it uncovered overbilling by Community Health while researching the offer, which Tenet has already rejected."

Here is Tenet's federal lawsuit (filed Dallas):
Tenet Complaint April 2011

Depuy pays $7.9 million to end UK bribe case

FierceMedicalDevices is reporting that "Johnson & Johnson's DePuy International unit has agreed to pay about $7.9 million to end a UK probe into whether it paid bribes to Greek officials to win contracts to supply orthopedic products. The news comes as the medical devices and pharma giant also agreed to pay $70 million in a settlement in related Foreign Corrupt Practices Act (FCPA) and oil-for-food investigations by the Department of Justice and the SEC."

Click here for the WSJ store (requires subscription).

Click here for a related DoJ press release.

Click here to learn more about the FCPA.

Click here for a guide to the FCPA.

Monday, April 11, 2011

Former WellStar president says he was fired for blowing the whistle

According to this news report, "the former president of WellStar Medical Group believes he was fired to prevent him from going public with alleged billing and revenue improprieties by some WellStar physicians. The health system's attorney denies the allegation.  WellStar Health System Interim CEO Jim Budzinski terminated Dr. Richard Lopes on March 21 without cause. WellStar claimed in a press release that Lopes had resigned. Not true, Lopes said in a March 24 letter to Budzinski."

HHS puts up searchable web page for HAC rates

The Hill is reporting that "Medicare beneficiaries for the first time will have access to data about hospital-acquired condition (HAC) rates, the agency announced on Wednesday, despite industry objections."  Click here for the HHS site.  Information is good.  The info provided, however, by the site seems to be general.  

But this leads to a fraud question: if a hospital knows that it is responsible for causing the HAC, may it bill Medicare for treatment?  And if it does, is that a false claim for the purposes of the False Claims Act?

Recent off-label case

Drug and Device Law Blog analyzes a recent decision by a U.S. District Court in Houston dismissing an off-label case. 

Sunday, April 10, 2011

DoJ intervenes in Alabama ambulance fraud case

The DoJ has intervened in a qui tam case against Rural/Metro Ambulance, an Alabama ambulance company.  The DoJ alleges the company violated the False Claims Act by submitting false claims for ambulance services that were never provided and were medically unnecessary.  "Medicare’s regulations cover the reimbursement of certain ambulance services only if such services are furnished to a beneficiary whose medical condition is such that other means of transportation are not advised.  This generally means that ambulance transportation is appropriate if the beneficiary is bed-confined or if the beneficiary’s medical condition, regardless of bed confinement, is such that transportation by ambulance is medically required. Each state’s Medicaid regulations contain similar provisions."  The DoJ alleges that Rural/Metro created or submitted documentation that falsely represented that a patient was either bed-confined or that transportation by ambulance was otherwise medically required when that was not the case. 

Ambulance fraud is a major problem, especially here in South Texas (San Antonio, Laredo, McAllen, Brownsville, Corpus Christi).  Click here for a CIA arising out of San Antonio.   

Saturday, April 9, 2011

Texas AG continues to prosecute Medicaid fraud

Below are slides that the Texas AG presented to the Texas Senate about its continuing Medicaid anti-fraud efforts.  Compared with other states, Texas is one of the few states that is serious about protecting its Medicaid program.  
 davidmorales_20110215

Friday, April 8, 2011

Recently unsealed opinion about relator's share--victory!

Below is a superb opinion by U.S. District Court (Houston) Judge Melinda Harmon, addressing the issue of relator's share.  It's frustrating that, on occasion, DoJ wants to shortchange a relator, despite substantial risk, money, and effort by the relator and his counsel.  But Judge Harmon's elegant opinion does a nice job of looking at the statutory language of the False Claims Act and the legislative history that shepherded the 1986 amendments through enactment. 
Pallares (Relator Share)

Texas has updated its Medicaid and CHIP stats

Click here for the link.

Miami-Area Marketing Director Pleads Guilty for Her Role in Community Mental Health Care Fraud Scheme Involving More Than $100 Million in Fraudulent Medicare Claims

A Miami-area resident pleaded guilty today in U.S. District Court in Miami for her role in managing a community mental health care fraud scheme that resulted in the submission of more than $100 million in fraudulent claims to Medicare, the Departments of Justice and Health and Human Services (HHS) announced.
Acevedo admitted that as marketing director, her job was to orchestrate the payment of kickbacks and bribes used to recruit Medicare beneficiaries to attend ATC and a related company, American Sleep Institute (ASI).   Acevedo admitted that the Medicare beneficiaries recruited by ATC and ASI, were not eligible to receive the PHP and sleep study services that ATC and ASI billed to Medicare, and that the services were not medically necessary.   During the period of her involvement in the fraud scheme, the defendant admitted that she and her co-conspirators caused between $100 million and $200 million in fraudulent claims to be submitted to Medicare for services purportedly provided at ATC and ASI.
According to court documents, Acevedo and others paid kickbacks to owners and operators of assisted living facilities (ALFs) and halfway houses and to patient brokers in exchange for providing ineligible patients to ATC and ASI.

South Texas rivals South Florida for health care fraud

South Florida is notorious for being the cesspool of health care fraud in the U.S.  But I've started to notice that South Texas has become the hotbed for health care fraud.  It's the Wild Wild West in South Texas (Victoria, Laredo, McAllen, Brownsville, Corpus Christi, Mission, Harligen, Edinburg, Hidalgo).  One problem is geographical distance.  The U.S. Attorney's Office for the Southern District of Texas has jurisdiction over the Valley, but, with its headquarters in Houston, is hundreds of miles away.  Fortunately, that office has staffed with some of the best health care fraud lawyers in the country.  And the current U.S. Attorney is from Laredo.  But compounding the problem is that almost all of the federal agents that investigate health care fraud (HHS, DCIS, FBI, VA-OIG) are also in Houston.  

Click here for a recent posting on this subject. 

Click here for a recent DoJ press release about the indictment of a McAllen DME provider.

Click here for another recent DoJ press release about the indictment of a McAllen urologist for Medicare fraud crimes.

Sophisticated patient identify theft ring tragets Colorado Springs

As reported in this story by a Colorado Springs news outlet, patient identify theft is becoming much more sophisticated:
A phony letter is circulating around town, using the familiar Memorial Health System logo to fool potential victims.  The warning comes via the hospital itself, after staffers became aware of the problem.Police are investigating the letter as a possible identity theft scam. According to a Memorial Health spokesperson, the letter falsely notifies people that vast amounts of personal information provided to Memorial may have been stolen.  A  statement issued by Memorial outlines what happens next: "The letter urges [recipients] to call a Miami-based phone number. Memorial has experienced no such security breach of personal information, and the Colorado Springs Police Department's Financial Crimes Unit is investigating."
Click here for an earlier post about massive patient identify theft case.

Click here another case. 

DoJ settles fraud case with German security guard firm

 Securitas GmbH Werkschutz has paid the United States 6,529,042 Euros (approximately $9.1 million) to settle allegations that the German company billed the Army, under contracts to provide security at U.S. Army installations in Germany, for guard hours not actually worked, the Justice Department announced today. The United States alleged that the overcharging violated the False Claims Act and brought counterclaims based on fraud in several actions that Securitas had filed against the Army in the Court of Federal Claims in Washington, D.C., seeking additional compensation under one of the contracts at issue, Securitas GmbH Werkschutz v. United States, Nos. 07-255/6/7C (Fed. Cl.)

Thursday, April 7, 2011

Sen. Grassley seeks to further protect whistleblowers

Sen. Grassley, who co-sponsored the 1986 amendments to the False Claims Act, has introduced a bill to further protect whistleblowers.  Here is an excerpt from his press release:
Senator Chuck Grassley has co-sponsored legislation to provide a much needed update to the Whistleblower Protection Act by restoring congressional intent of the original law. Grassley said that whistleblowers are being denied the protections they should have under the law because of decisions of the Merit Systems Protection Board, the Federal Circuit Court of Appeals, and the general anti-whistleblower sentiment held by those in executive branch agencies. 

Ohio seeks to enact a False Claims Act--Republicans on the vanguard

One appealing aspect of a False Claims Act is it enjoys bi-partisan support.  Ohio, which doesn't have a FCA, appears to be on the cusp of enacting one through the strong efforts of its staunch-conservative Attorney General Mike DeWine.  Here is how the Columbus Dispatch reports on recent developments in Ohio:

A "whistleblower" law to give protection -- and a financial incentive -- to people who provide information about alleged fraud in state spending was backed today by Attorney General Mike DeWine.  "More than half the states have it. The federal government has it. They have a good experience with it," DeWine said at a Statehouse press conference. "At a time when every penny counts, we must do all we can to recover as much as possible for Ohio and our taxpayers."  The state False Claims Act is being introduced by two Republican senators: Jim Hughes of Columbus and Scott Oelslager of North Canton. It must be passed by both chambers and signed by the governor to become law.  The proposal would provide protection for people who come forward with information about fraudulent spending -- and a share of the amount recovered if the case is successfully prosecuted.

BMS Intervention Press Conference

Click here for the press conference by California Commissioner Dave Jones regarding California's intervention into the BMS case.   Click here for my earlier post on this case.  Stay tuned . . . this is an important case. 

Wednesday, April 6, 2011

New study about Pharma's off-label marketing strategies

Overtime, we are starting learn how Pharma engages in illegal off-label marketing.  See the study below.  Keep in mind, this study is based solely on unsealed qui tam cases.  These cases only scratch the surface of what has been going on.
Journal.pmed.1000431

Gwen Olsen -- Confessions of an Drug Pusher

Meet Gwen Olsen, author of Confessions of an Rx Drug Pusher.  See the video below for her story.  I found her off-label "Haldol blitz" in South Texas credible from what I have seen in some of our investigations.  

Click here for a story in the Washington Times.  

Tuesday, April 5, 2011

Pfizer paid US docs $177 million in 2010

FoxBusiness.com breaks down Pfizer's payments to US docs in 2010:
  • $34.4 million in speaking fees to about 4,600 professionals to discuss Pfizer products and health topics at events with other professionals.
  • $18 million worth of meals, much of which were provided to doctors in their offices by Pfizer sales representatives.
  • $8.9 million in professional advising fees to 1,400 doctors.
  • $5.8 million in travel expenses.
  • $1.7 million in education items.

HHS-OIG determines most states' FCAs are inadequate

FCA Alert has a posting about how HHS-OIG has determined that most states' FCA fail to meet federal mandates (note, the Health Care Act shifted the goalposts).  FCA Alert explains why it is important to a state that its FCA meet federal mandates:
Federal law provides a financial incentive to a state with legislation that is in compliance by increasing that state’s share of monetary recovery from any lawsuit brought under the state's false claims act by 10 percent.  To qualify for this incentive, the OIG in consultation with the Attorney General must determine that the state false claims act satisfies four requirements:  (1) the state law establishes liability to the state for false or fraudulent claims described in the federal FCA with respect to any expenditures related to the state’s Medicaid plan; (2) the state law contains provisions that are at least as effective in rewarding and facilitating qui tam actions for false or fraudulent claims as those described in the federal FCA; (3) the state law contains a requirement for filing an action under seal for 60 days with review by the state attorney general; and (4) the state law contains a civil penalty that is not less than the amount of the civil penalty authorized under the federal FCA.

Rex Healthcare To Pay $1.9 Million To Resolve Kyphoplasty-Related FCA Allegations

Financial Fraud Law is reporting that "Rex Healthcare, a 655 bed hospital in Raleigh, N.C., has agreed to pay the United States $1.9 million, plus interest, to settle allegations that it submitted false claims to Medicare. The government alleged that the hospital routinely submitted claims to Medicare for a variety of minimally-invasive procedures during the period 2004 through 2007, which the hospital classified as inpatient admissions in order to increase its reimbursement from Medicare, despite the absence of medical necessity justifying the more expensive inpatient admissions."  

Click here for the DoJ press release.

It is fairly easy for a hospital to commit this type of fraud.  I blogged earlier how CMS is trying to crack down on this type of fraud.  But it's almost imposbile given our third-party reimbursement system is based upon honesty and not everyone is honest.

FDA now seeking to hold Pharma executives responsible

Drug Topics is reporting "FDA has a new target in its continuing efforts to clean up pharmaceutical industry abuses: individual corporate officials. The most recent targets are the vice president of quality and the vice president of operations for OTC Products at McNeil Consumer Healthcare, a subsidiary of Johnson & Johnson. The two are named as defendants in a consent decree of permanent injunction for failing to comply with current good manufacturing practice requirements at plants in Pennsylvania and Puerto Rico that resulted in massive product recalls."

GSK paid $56.8 million for speaking fees in 2010 to US health care professionals

The UK's Telegraph is reporting GSK, Britain's biggest pharma company, "said it had paid $28.5m (£17.7m) in 2010 to institutions involved in 127 studies, with 595 different lead researchers. . . . The drug giant has previously given details on payments to speakers and in the latest figures, also revealed on Thursday, GSK said it paid out $56.8m last year to 5,331 US health care professionals for speaking on behalf of GSK or giving it advice."

Pharma companies starting to disclose payments to doctors

The Philadelphia Inquirer has a story showing "some pharmaceutical companies now disclose payments they make to doctors for speaking engagements or consulting and to researchers, hospitals, and other medical institutions for clinical studies."  (Look at the screen grab from Pfzier's web page.  Disclosures should be much more robust by 2013.)  Now if we can only find out how much a doctor earns from Medicare . . .  

Monday, April 4, 2011

DoJ joins False Claims Act case against Healthpoint

DoJ issued a press release on April 1 (but it was no April fools' day joke) that it "has filed a complaint against Healthpoint Ltd., alleging civil False Claims Act violations arising from the company’s sale of an unapproved prescription drug that was ineligible for payment under Medicaid and Medicare, the Justice Department announced today.  In the complaint, filed in the District of Massachusetts, the government alleges that the Ft. Worth, Texas-based subsidiary of DFB Pharmaceuticals Inc., submitted false statements concerning the regulatory status of Xenaderm to the United States, thereby causing false or fraudulent prescription claims for the unapproved drug to be submitted to Medicaid and Medicare."


 

CMS delays policy requiring signatures for diagnostic lab tests

FierceHealthCare is reporting CMS "delayed on Friday implementation of a policy requiring signatures of physicians or other clinicians to approve requisitions for clinical diagnostic laboratory tests. The policy, scheduled to go into affect on April 1, will not be enforced this year – the second time since December the agency has delayed its implementation."  

There is lots of political pressure on this issue.  See the links to the letters at the bottom of the article from high Senators and Congressmen.  But in our investigations, we've seen that a physician certification or at least signature is an effective way of preventing fraud.

HHS-OIG has updated its CIA page

HHS-OIG has updated its Corporate Integrity Agreements page.  Click here.

Thomson Reuters Launches New Service to Combat Healthcare Fraud, Waste, Abuse

Thomson Reuters announced that it is a rolling out a new service to combat health care fraud.  Here is how T-R describes its new service.
CLEAR for Healthcare Fraud takes specific industry data and key provider content such as NPI (National Provider Identifier) numbers, sanctions data and professional licensing information, and combines it with a deep collection of utility records, cell phone data and other public records, to provide a powerful search tool that can pinpoint not just minor data aberrations, but true inconsistencies warranting further investigation. The results of those investigations can help remove fraudulent healthcare providers from Medicare and Medicaid payrolls and recover billions of dollars in wasteful spending.
Here are a few more examples of the kinds of results CLEAR for Healthcare Fraud can deliver:
  • A medical transportation company reports a suspiciously high number of transports. A search in CLEAR’s records turns up only two vehicle registrations for that company, prompting an investigation.