Federal officials seem wary about their words and their dissemination. At the Health Care Compliance Association’s (HCCA’s) fourth annual Healthcare Enforcement Compliance Conference, top U.S. Department of Justice (DOJ) officials provided an update on current developments related to criminal and civil fraud investigations.  While a future article will focus on…

Filing marks shift in nature of healthcare litigation of this nature. The whistleblower cases I report on for RACmonitor typically are brought by the quintessential whistleblower – a healthcare industry insider who has observed first-hand fraud perpetrated by his or her employer and who, having brought the matter to the…

The whistleblower brought this suit under the federal False Claims Act. The False Claims Act (FCA) allows a private party (known as a “relator” or “whistleblower”) with inside information about fraud against the government to file a lawsuit on the government’s behalf and receive 15 to 30 percent of the…

The whistleblower brought this suit under the federal False Claims Act. In February 2014, whistleblower Sarah Benhke, the former senior Medicare Part D actuary at Aetna, filed a sealed complaint against CVS Caremark, the pharmacy benefit management department of healthcare giant CVS Health, accusing the company of billing Medicare Part…

This is the third time that the nurse has brought a successful whistleblower lawsuit against a hospital system where she has worked. Banner Health, a Phoenix-based health system that owns 28 hospitals across six states, agreed to pay over $18 million to settle allegations that 12 of its hospitals in…

If this hospital was targeted by the DOJ, where does that leave everyone else? Today I have a great mystery to present. Last week the U.S. Department of Justice (DOJ) announced a $1.88 million False Claims Act settlement with Genesis Medical Center in Davenport, Iowa. In the settlement, the DOJ…

Whatever you do, don’t bring patients back for a procedure another day just for the purposes of billing. Determining when to use Modifier 25 can be challenging, and reasonable people can differ about whether it is appropriate in a particular situation. When a patient needs a procedure on the day…

Recent press coverage misleadingly suggested that the ruling was a serious setback to the government’s suit, which is not the case. On Feb. 12, 2018, a federal judge in the Central District of California issued his ruling on the UnitedHealth Group’s (UHG) motion to dismiss the government’s complaint in one…

A recent False Claims Act case highlighted a range of perils. Scripps Hospital recently paid $1.5 million to resolve a False Claims Act (FCA) case. There are several lessons to be learned from the complaint and settlement.   First, when an FCA case is first announced or settled, people typically turn to…

A False Claims Act case pits a prominent health system against its EHR software provider. Over the last many years, healthcare providers have been financially incentivized to purchase electronic health records (EHR) software. These programs can cost upwards of $25,000 to $50,000, and, sometimes are renewable every year. In other…