Tag Archives: Qui Tam Whistleblower Cases

Rock Island, Illinois home health supplier faces vendor fraud charges for submitting false billing invoices.

How you can stop home health fraud, Whistleblowers may share in recovery

Home health companies are increasingly popular among families who want their loved one to receive care in their own home or another residential location with others receiving care. Home health options are appealing to those who do not favor the traditional nursing home facilities and find them to seem institutional. One advantage of a traditional nursing home setting may be the close monitoring and control of the healthcare professionals who work with residents. Too often the news reports include stories of home health operations failing their residents and failing the system. There are cases of negligent care and abuse of home health residents as well as cases of fraud and financial deceit. When individuals are tempted by the chance to get a little extra from the government, that little extra tends to become more. Many caught in home health fraud schemes are able to take significant amounts of money before they are stopped. How would you know your loved one was cared for by individuals engaging in home health fraud? What questions about the quality of care would keep you up at night?

Is there a way to know whether home health care givers are honest and trustworthy?

When choosing in home healthcare options, it is important to do your research and conduct due diligence by investigating the backgrounds of the individuals who may be caring for you or your loved one. For less than 100 dollars you can obtain background investigative reports for home health professionals. Professional licenses can be verified and in the process, any reports of discipline of that professional may be available. If you are not comfortable or particularly skilled at online investigation, our law firm can assist you or recommend another who may be better able to help you in the vetting process. Unfortunately, it may be difficult to tell whether the individual of any character is engaged in or connected to a fraudulent operation.

Medicare billing fraud cases are reported frequently and investigations lead to convictions.

When people picture Medicare fraud, the image may be a dark basement with leaking pipes and a crooked looking person working at a desk with a sinister look and laugh. In reality, the setting may be right outside your window or down the street. The suburban landscape is ripe with reports of home health fraud. In Schaumburg, Illinois, a 47 year-old woman was convicted on 21 counts of fraud and making false statements; and sentenced to 72 months, with an order to pay 15.6 million dollars in restitution. “Home-health fraud has become a significant problem nationally and particularly in the Chicago area,” Assistant U.S. Attorney Stephen Chahn Lee argued in the government’s sentencing memorandum. “Such fraud cannot happen without people like the defendant, who abuse Medicare’s rules and abuse the trust placed in them by Medicare and their patients.[i]

Examples of Medicare billing fraud.

In this recent fraud case in Schaumburg, the woman leading the fraud directed her employees to conduct in-home visits for patients who did not need care, people who were not home-bound and quite able and otherwise healthy. When the employees billed Medicare for the visits, they billed for the more expensive and complicated levels of care, even though no care was needed or often performed. The inflated billing and billing for services not needed is an easy fraud to hide if nobody is looking.

Billing Medicare for services not actually needed or performed is such big business that some fraud operations offer kickbacks to individuals who recruit and sign up new home health patients, regardless of their health condition, so long as they qualify for Medicare services and a bill for something can be generated.

How do the frauds become exposed, investigated and stopped if nobody is looking?

Whistleblowers lead to investigations and convictions for home health fraud where Medicare is duped into paying for services never needed or rendered. If one of the nurses working for the woman leading up the Schaumburg fraud scheme was the whistleblower and reported the fraud to authorities, that person would be paid a part of the restitution ordered, in this case that would be a cut of the more than 15-million-dollar restitution.

If you or someone you know suspects others are profiting from home health fraud, you can contact our law firm by dialing 773-631-4580 to learn about your rights under the law and whether you may be able to stop a home health operation engaging in fraudulent practices.

Michael V. Favia & Associates, P.C. is a health law and litigation firm in Chicago representing individuals, healthcare professionals and organizations with civil legal matters as well as professional licensing and regulation. We frequently publish information and resources to help healthcare professionals and individual consumers more knowledgeable about news and occurrences in health.

Chicago health law and litigation attorney Michael V. Favia and his associates in several locations and disciplines, advise and represent private individuals as well as healthcare professionals in all types of litigation and administrative matters involving licensing and regulatory agencies.

Michael V. Favia and Associates, P.C. represents individual physicians and health care organizations in the Chicago area with a variety of legal matters. With offices conveniently located in the Chicago Loop, Northwest side and suburban meeting locations, you can schedule a discrete meeting with an attorney at your convenience and discretion. For more about Michael V. Favia & Associates, call us at (773) 631-4580, please visit www.favialawfirm.com and feel free to “Like” the firm on Facebook and “Follow” the firm on Twitter. You can also review endorsements and recommendations for Michael V. Favia on his Avvo.com profile and on LinkedIn.

 

[i] eNews Park Forest, Head of Schaumburg Home Health Company Sentenced to Six Years for Scheming to Fraudulently Bill Medicare for Unnecessary Care, Chicago ENEWSPF, July 26, 2016.

Dr. Whistleblower: Reporting $10 million in a Medicare billing fraud scheme, could share in recovery

The Illinois Department of Financial and Professional Responsibility investigates cases that can lead to discipline.

The Illinois Department of Financial and Professional Responsibility investigates cases that can lead to discipline.

Former CEO of a physician-hospital practice venture, Robert Dannenhoffer, MD, filed a lawsuit in federal court alleging his former employer terminated the doctor’s position in retaliation for Dannenhoffer reporting a $10 million Medicare fraud scheme. Dr. Dannenhoffer led investigators to discover a fraudulent payment scheme, by which doctors were being compensated more money in exchange for prescribing certain medical procedures and prescription medications to Medicare patients, regardless of whether they were necessary, according to reports. The lawsuit alleges violations of the False Claims Act and the Stark Act, a federal patient referral law. As a whistleblower under federal law, Dr. Dannenhoffer seeks and may be entitled to the reinstatement of his position, back pay, punitive damages and attorney’s fees.[i]

Medicare Fraud is often reported and exposed by whistleblowers who may share in court awards.

Medicare fraud costs U.S. taxpayers significant money every year when fraudulent reimbursements and overpayments are claimed and paid for treatments never provided to patients, suppliers billing for equipment never obtained and even the use of false information to mislead an individual to joining a Medicare plan. Doctors in physician-hospital practice ventures, like Dr. Dannenhoffer, may be liable for Medicare fraud occurring in their practice, even despite their potential lack of personal knowledge. By reporting the suspected fraudulent behavior as a whistleblower, a physician like Dr. Dannenhoffer not only may avoid liability for fraud, they may recover a percentage of any amounts for which the case settles or for which a judge rules in favor of the government.

Dr. Dannenhoffer is the whistleblower in this Medicare fraud scheme in which over $10 million worth of fraudulent and inflated Medicare payments are identified. The doctor claims that after he filed his federal whistleblower lawsuit, he was fired as CEO of the major healthcare provider where he worked and was blacklisted in the medical community.

The doctor claims his healthcare company violated the False Claims Act and the Stark Act.

False Claims Act violations are not taken lightly. In this case, Halifax Health settled for $85M.

False Claims Act violations are not taken lightly. In this case, Halifax Health settled for $85M.

Federal law codified in the False Claims Act (FCA)[ii] imposes liability on individuals and organizations, often federal contractors, who defraud government programs such as Medicare. The FCA, imposes damages and penalties for any individual who knowingly submits or causes another to submit a false claim to the government, or knowingly makes a false record or statement to obtain a false claim paid by the government. The current amounts of penalties can amount to three times the dollar amount of the claim plus fines of $5,500 – $11,000 per claim.

An individual reporting Medicare fraud may also file an intervening lawsuit on behalf of the government, a qui tam action, and the whistleblower’s identity is kept under seal. The whistleblower may share in the financial settlement or recovery, between 15 and 25 percent of the amount. The law works this way to encourage more individuals to step forward and report Medicare fraud.

The Stark Law[iii] is a section of the Social Security Act and is known as the physician self-referral law. Physicians may not make referrals and receive payment Designated Health Services[iv] payable by Medicare to an individual or group where the physician or their immediate family member are an owner or have an ownership interest. In this case, Dr. Dannenhoffer was not allowed to make referrals to the organized medical service venture in which he was a partner with interest.

Being a whistleblower has its costs, but it is better to discover and report Medicare violations, than to worry about civil and criminal liability for participating or failing to report fraud.

The laws involving fraud are frequently tightening and are stricter in the enforcement of the False Claims Act.

The laws involving fraud are frequently tightening and are stricter in the enforcement of the False Claims Act.

Michael V. Favia and Associates can help physicians who learn or receive notice of Medicare fraud activities. With many local, state and federal agencies working together to investigate and stop health care billing fraud, reporting a violation as a whistleblower may be the only option an individual has when they otherwise could face civil and criminal liability and penalties, including imprisonment. Of course, Favia and his team can also offer physicians a review of their billing procedures and protocols to assess risk and exposure to potential fraud. When your chain is only as strong as its weakest link, it makes sense to regularly examine that chain.

Chicago health law, litigation and professional licensing attorney, Michael V. Favia and the associate attorneys of Michael V. Favia and Associates, P.C. represent individual physicians and health care organizations in the Chicago area with a variety of legal matters. With offices conveniently located in the Chicago Loop, Northwest side and suburban meeting locations, you can schedule a discrete meeting with an attorney at your convenience and discretion. For more about Michael V. Favia & Associates, please visit www.favialawfirm.com and feel free to “Like” the firm on Facebook and “Follow” the firm on Twitter. You can also review endorsements and recommendations for Michael V. Favia on his Avvo.com profile and on LinkedIn.

[i] Beckers Hospital Review, Ex-CEO claims retaliation for blowing the whistle on $10M in false Medicare charges, by Ayla Ellison, Jan. 27, 2016.

[ii] The False Claims Act 31 U.S.C. §§ 3729–3733

[iii] The Stark Act 42 U.S.C. § 1395nn

[iv] Designated Health Services under the Stark Law

Medicare fraud and kickbacks: Chicago psychologist loses his medical license indefinitely

Dr. Reinstein prescribed an alarming amount of clozapine to Illinois patients for kickbacks.

Dr. Reinstein prescribed an alarming amount of clozapine to Illinois patients for kickbacks.

Chicago area psychologist, Michael Reinstein, recently lost his medical license following the Illinois Department of Financial and Professional Regulation (“IDFPR”) suspended his license for a minimum of  three years before Reinstein would be allowed to apply for reinstatement. When complaints of professional misconduct come to the attention of IDFPR, the licensing authority for many Illinois professionals, the IDFPR may cooperate with other state agencies to prevent further harm to Illinois residents. In this case, there was a determination that the doctor received, “Illegal direct and indirect remuneration” from the maker of generic clozapine. Further, reports indicate he did not consider alternative treatments and disregarded their well-being in the name of profit, according to a recent news report.[i]

Generally, the generic drug clozapine is used in the management of antipsychotic disorders, like schizophrenia, when nothing else works. According to a reputable website on pharmaceuticals, this because the drug carries a “concern for the side effect of agranulocytosis [reduction in white blood cell count], clozapine should be reserved for patients who have failed to respond to other standard medications or who are at risk for recurring suicidal behavior.[ii]

The Chicago Tribune published a 2009 story about Dr. Reinstein, highlighting the alarming amount of the antipsychotic clozapine prescribed to his patients. In 2007, he prescribed more clozapine to Illinois Medicaid program patients than, “all doctors in the Medicaid programs of Texas, Florida and North Carolina combined.[iii]

Dr. Reinstein was investigated by the U.S. Department of Justice who accused him of fraud. The U.S. District Court for the Northern District of Illinois stated in a press release that the doctor, “received illegal kickbacks from pharmaceutical companies and submitted at least 140,000 false claims to Medicare and Medicaid for antipsychotic medications he prescribed for thousands of mentally ill patients in area nursing homes.[iv]

Medicare fraud is prosecuted under the False Claims Act.

The lawsuit against Dr. Reinstein, the largest civil case alleging prescription medication fraud, is the largest ever brought in Chicago against an individual. The U.S. Attorney’s press release reports that the doctor kept an office in the Uptown neighborhood on Chicago’s north side, where there is a large population of mentally ill nursing home residents. The predatory nature of prescribing strong medications that people might not need, especially when they might lack the capacity to understand and get a second opinion, is in part what is so shocking to people who find out such bad acts were happening so close to home.

The False Claims Act helps expose and prosecute those who make bogus claims for payment through government programs. To encourage people to speak up when they see something wrong, the whistleblowers are rewarded in a percentage of the amount recovered in a successful lawsuit. To learn more about whistleblower protection and the False Claims Act, under which Dr. Reinstein is held accountable, read our article, False Claims Act lawsuits and the whistleblowers who share in recoveries.

The IDFPR, in efforts to protect Illinois residents from wrongdoing professionals, takes action in an effort to protect people against future harms by the individual. You can review the August 8, 2014, IDFPR Order, finding and recommending that Dr. Reinstein’s Physician and Surgeon License be indefinitely suspended for a minimum period of three years. The doctor may wish to apply for reinstatement, but under other recent news we will share in a follow-up article, it is becoming harder to get a professional license reinstated after this type of discipline by the IDFPR.

If you believe you are aware of Medicaid and Medicare fraud, Attorney Michael V. Favia can help.

Michael V. Favia is a health law and litigation attorney whose practice includes IDFPR litigation. Favia is experienced in complex litigation involving government contract and similar types of fraud. Favia’s extensive health care law and litigation career allows him and a skilled group of associate colleagues the benefit of experience in representing clients with qui tam claims for violations of the False Claim Act. Michael V. Favia & Associates are available to help and meet for client consultations with offices conveniently located in the Chicago Loop, Northwest side and suburbs so you can schedule a discrete meeting with an attorney at your convenience and discretion. For more about Michael V. Favia & Associates’ professional licensing work, please visit www.IL-Licensing.com and feel free to “Like” the firm on Facebook and “Follow” the firm on Twitter.

[i] ProPublica, Illinois Suspends Medical License of Leading Prescriber of Antipsychotic Drugs, by Charles Ornstein, Aug. 11, 2014.

[ii] MedicineNet website, clozapine.

[iii] ProPublica, In Chicago’s Nursing Homes, a Psychiatrist Delivers High-Risk Meds, Cut-Rate Care, by Christina Jewett, ProPublica, and Sam Roe, Chicago Tribune, Nov. 10, 2009.

[iv] U.S. Department of Justice, United States Attorney for the Northern District of Illinois, Chicago Psychiatrist Allegedly Submitted At Least 190,000 False Claims to Medicare and Medicaid; Lawsuit Alleges Kickbacks to Prescribe Antipsychotic Medication for Nursing Home Patients, Nov. 15, 2012.