Sessions creates opioid fraud detection unit, focuses on 12 districts

Twelve federal districts have been selected to participate in an Opioid Fraud and Abuse Detection Unit, created by the Department of Justice (DOJ). The DOJ will fund twelve Assistant United States Attorneys for three year terms to focus solely on investigating and prosecuting fraud related to prescription opioids. Attorney General Jeff Sessions announced the program’s formation at the Columbus Police Academy in Ohio.

Data analytics program

The unit will consist of a data analytics program, which will allow targeted investigation and prosecution. Sessions stated that the team would use such information as physicians who prescribe opioids at a higher rate than peers, the average age of patients receiving the prescriptions, and pharmacies dispensing large amounts of opioids to focus its investigation.

The federal prosecutors, located in districts across the country, will work with various agencies to investigate and prosecute opioid fraud, including pill mills and unlawful diversion of opioids. Most of the districts are located in the east and Midwest, such as Florida, Michigan, Alabama, Kentucky, Ohio, and West Virginia.

Atlanta pain clinic feels financial hurt after allegedly bending Medicare rules

Atlanta Medical Clinic (AMC) and its owner agreed to pay $250,000 to settle False Claims Act (FCA) (31 U.S.C. §3729 et seq.) allegations that the clinic billed Medicare for services performed by a suspended physician and for administering drugs that were not approved by the FDA.

Suspended physician

An AMC physician was suspended from the Medicare program in June 2013 for making false statements regarding his criminal history. Despite the suspension, AMC allegedly continued to claim and receive payment for medical services rendered by the physician. Because of the suspension, none of those services were eligible for Medicare reimbursement and, therefore, reimbursement claims related to those services constituted false claims. AMC allegedly circumvented the suspension by submitting claims for services performed by the physician as though they were performed by another physician.

Unapproved drugs

AMC also, allegedly, violated the FCA by seeking and obtaining reimbursement for a Canadian, non-FDA approved knee treatment drug—Orthovisc®. The alleged claims are false because Medicare does not cover the cost of foreign, non-FDA approved treatments.

Fraudulent claims submitted to TRICARE for unnecessary medications ends in guilty pleas

In related cases, a pharmacist and pharmacy marketeer, both of Mississippi, pled guilty to conspiracy to commit health care fraud in a scheme that defrauded TRICARE, according to a July 25, 2017, announcement by the Department of Justice (DOJ). The pharmacist and his co-conspirators received at least $192 million in payments for medically unnecessary medications from TRICARE and private insurance companies. In the case of the pharmacy marketeer, TRICARE made payments of approximately $2.3 million for false and fraudulent claims submitted by the pharmacy. Sentencing hearings are scheduled for October 17, 2017.

The pharmacist’s role

The pharmacist pleaded guilty to one count of conspiracy to commit health care fraud and money laundering for dispensing medically unnecessary compounded medications and causing fraudulent claims to be submitted to TRICARE. Plea documents revealed that the pharmacist admitted that he (1) conspired with others to select compounded medication formulas based on profitability rather than on effectiveness or patient need, and (2) conspired with the pharmacy co-owners to avoid fraud prevention measures, such as collecting copayments, to incentivize patients to receive medically unnecessary medications.

The marketeer’s role

The pharmacy marketeer pleaded guilty to one count of conspiracy to commit health care fraud for his role in the scheme to defraud TRICARE. Plea documents indicated that the marketeer admitted to (1) soliciting physicians and other medical professionals to write prescriptions without seeing patients for medically unnecessary compounded medications dispensed by the pharmacy; and (2) conspiring with others to falsify patient records to make it appear as though medical professionals had seen patients prior to the date prescriptions were written.

Houston physician found guilty for role in $1.5M fraud scheme

Following a four-day trial, a Houston-area physician was convicted of conspiracy to commit health care fraud and conspiracy to pay and receive illegal kickbacks in a scheme involving home health services involving Allied Covenant Home Health, Inc. (Allied). Sentencing is scheduled for September 25, 2017.

Scheme

According to the Department of Justice (DOJ), the physician was involved in a scheme to defraud Medicare by submitting $1.5 million in fraudulent claims from 2006 to 2013. Evidence showed that the physician admitted patients for home health services through Allied without regard for qualification for such services. The physician falsified medical records and signed false documentation to show that patients met Medicare criteria for home health service reimbursement when they did not.

The evidence also showed that the physician paid illegal kickbacks to the owner of Harris Health Care Group (Harris). These kickbacks were paid in order to facilitate Medicare billing for facet injections. These injections were not medically necessary or not provided.