December 5, 2019
By Ellen Fink-Samnick MSW, ACSW, LCSW, CCM, CRP
Medicare Advantage and the Saga of Scrutiny
The saga of increased scrutiny of Medicare Advantage plans continues to unfold. UnitedHealthcare’s SuspensionCMS announced a suspension of one year for the UnitedHealthcare H5322 contract for not reaching the mandatory 85percent medical loss ratio (MLR). Plans must achieve that magic medical loss ratio on an annual basis. For those unfamiliar…
June 20, 2019
By Mary Inman, Esq. and Max Voldman, Esq.
First major pharmaceutical executive convicted on criminal charges related to opioid crises
Insys founder found guilty of racketeering in connection with bribes to prescribe potent opioid spray. On past Monitor Monday programs, we have reported on John Kapoor, the former CEO of opioid giant Insys Therapeutics Inc., who has been under indictment since October 2018 for alleged violations of the Anti-Kickback Statute…
June 6, 2019
By Mary Inman, Esq. and Max Voldman, Esq.
Intermountain Drops Supreme Court Challenges to False Claims Act with Settlement of Whistleblower Suit
Healthcare system drops petition to the U.S. Supreme Court to challenge the constitutionality of the whistleblower provisions of the False Claims Act Last month, several media outlets reported that Intermountain Health, a Utah-based health system that operates 22 hospitals and dozens of group clinics, urgent care facilities, a home healthcare…
By Mary Inman, Esq. and Max Voldman, Esq.
Allegations were made of kickbacks in the form of co-pay waivers. Late last month, US WorldMeds, a pharmaceutical manufacturer, agreed to pay the U.S. Department of Justice (DOJ) $17.5 million to resolve two whistleblowers’ claims that it violated the False Claims Act (FCA) by paying kickbacks to patients and doctors…
By Mary Inman, Esq. and Max Voldman, Esq.
CHS and Medhost have categorically denied all of the allegations in the complaint. As the use of electronic health records (EHRs) has expanded at a rapid pace, so too has the fraud associated with these systems. An EHR is a digital version, or database, of a patient’s paper charts. The…
By Mary Inman, Esq. and Max Voldman, Esq.
Filing focuses on generic drug costs levied by pharmacies absorbed by the pharmacy giant. In 2013, J. Douglas Strauser, a pharmacist, filed a whistleblower lawsuit against Stephen L. LaFrance Holdings Inc. and Walgreens, alleging that they overcharged Medicaid for generic drugs by not giving the government the best price. Stephen…
February 21, 2019
By Mary Inman, Esq.
Court Poised to Rule on Motions to Dismiss Key Whistleblower Case
Decision expected soon in the Providence lawsuit. As regular Monitor Monday listeners know, we have been closely tracking the progress of data analysis firm Integra Med Analytics’ whistleblower lawsuit against Providence Health and its consultant J.A. Thomas and Associates, Inc. (JATA), alleging a conspiracy between Providence and JATA to upcode…
February 13, 2019
By Mary Inman, Esq.
Lawsuit by Policyholders Targets Anthem
Individual policyholders in Georgia launch a class-action lawsuit against Anthem for deceptive sales. Early last week, Frances Kirby and John David Marks, two individual policyholders from Cook County, Georgia, filed a class-action lawsuit in federal court in Atlanta against Anthem and Blue Cross Blue Shield of Georgia for allegedly misleading…
September 6, 2018
By Frank D. Cohen, MPA, MBB
Developing: Providence Whistleblower Case: An Analysis of the Analysis
Not enough information in the public use databases to know that a claim is fraudulent. “In God we trust; all others bring data.” That is what the sign above my desk says, right next to my six-foot slide rule. I was pondering the truth behind this tongue-in-cheek saying when I…
August 30, 2018
By Mary Inman, Esq.
Integra Med Analytics Files Whistleblower Lawsuit against Providence Health & Services and J.A. Thomas and Associates
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…
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Allen Jost, PhDAlvin Gore, MD, CHCQM and Cathi Charlberg, LVN, CHCQMAmanda Gilliland, RN, BSNAmber Soucy, MSN, RNAndrew B. Wachler, Esq.Andrew B. Wachler, Esq. and Emma E. TrivaxAndrew H. Hughes, MD and Charles Locke, MD, CHCQM-PHYADVAndrew Wachler and Kaitlin NucciAndrew Wachler, Esq., and Sarah Hillegonds, Esq.Angela Phillips, PTAspen AlbrightBarbara Vandegrift, RN, BSN, MABecky Rodrian, CPC, CEMC, CBCS, MBSBenjamin Kartchner MD, CHCQM-PhyAdvBrian T. LandryChristina Panos, RHIA, CTRChristopher Halleman, DOChristopher J. Laney, Esq.Chuck BuckClark AnthonyColleen Morley, DNP, RN, CCM, CMAC, CMCN, ACM-RNDaniel Zirkman, MDDavid A. McKenzie, CAEDavid M. Glaser, Esq.Delilah Davis, RN, BSN, CCADenise Coleman, LPNDenise Nash, MD, CCS, CIMDheeraj Mahajan, MD, FACPDuane Abbey, PhD, CFPEdward Roche, PhD, JDElizabeth C. Dunbar, MD, MBA, FACEP, CHCQM-PHYADVEllen Fink-Samnick MSW, ACSW, LCSW, CCM, CRPEllen Parucka Walker LCSW ACSWErica E. Remer, MD, FACEP, CCDSErin Diesel Roumayah, Esq.Frank D. Cohen, MPA, MBBGlenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FCS, C-CDAMGloryanne Bryant, RHIA, RHIT, CCS, CCDSGreg FordHolly Louie, RN, BSN, CHBMEJ. Paul Spencer, CPC, COCJanelle Ali-Dinar, PhDJeffrey D. Lehrman DPM, FASPS, MAPWCAJessica Forster, Esq.John K. Hall, MD, JD, MBA, FCLM, FRCPCJuliet B. Ugarte Hopkins, MD, CHCQM-PHYADVKathleen K. Borchard, BSN, RN-ACMKathy Seward, MD, CHCQM-PHYADVKim T. Charland, BA, RHIT, CCSKnicole C. Emanuel Esq.Kristi Pollard, RHIT, CCS, CPC, CIRCC, AHIMA-approved ICD-10-CM/PCS trainerLaurie M. Johnson, MS, RHIA, FAHIMA AHIMA Approved ICD-10-CM/PCS TrainerLeslie Marsh, RN, BS, MSN, MBALori O’Hara, MA, CCC-SLPMadison AllenMaggie Elehwany, JDMark SpiveyMarvin D Mitchell, RN, BSN, MBAMary Beth Pace, RN, BSN, MBA, ACM, CMACMary Inman, Esq. and Anne Hayes Hartman, Esq.Mary Inman, Esq. and Max Voldman, Esq.Matt Lambert, MDMatthew AlbrightMaureen Testoni Esq,Max Voldman, Esq.Melinda Battaile, MD, FHM, MMCI, CHCQM-PHYADV, CCDSMichael A. Salvatore, MD, FACPMichael KennedyMichael Rosen, Esq.Nancy J. Beckley, MB, MBA, CHCNena Scott, MSEd, RHIA, CCS, CCS-P, CCDSPhillip Angello, MDRalph Wuebker, MD, MBARichard “Dick” Beckley, YNS, USN, 1966-1970Ronald Hirsch, MDSarah Hillegonds, Esq.Sean M. Weiss, CEMA, CMCO, CPMA, CPC-P, CMPE, CMPM, CPC-P
