Periodically, we review the Centers for Medicare & Medicaid Services enforcement action docket. There are literally tens of thousands of healthcare providers across the country. Most participate in the Medicare or Medicaid health programs. The government periodically audits a small percentage of these providers each year.
When a significant problem is uncovered, the government can fine the provider or in some cases shut them down. This posts looks at some of the more significant audit findings for the first half of 2014.
The companies on the list include:
Geisinger Health System
Moda Health Plan
Cambia Health Solutions
Express Scripts Medicare
Tufts Associated HMO
Independent Health Association Inc
Lifetime Healthcare
Simply Healthcare Plans
Why are we looking into these companies? The answer is simple. The government has already concluded that these providers were not following certain rules. The violations were serious enough to warrant fines of $100,000 or more.
We are False Claims Act whistleblower lawyers. The cases we handle are typically not uncovered by a government audit. Providing medically unnecessary treatment or billing for services not performed are violations that usually come to light when a whistleblower comes forward. Whenever we see providers with what we believe are lax internal controls, we ask ourselves, “Is there anything else going on there?”
If, for example, a pharmacy or drug company is overbilling Medicare or dispensing drugs for off label or nonapproved purposes, the company can be fined. Assuming a whistleblower was instrumental in the recovery, a substantial cash award is possible.
We certainly are not suggesting the companies in this post are guilty of anything. But the government’s audit findings have us interested and we hope to speak to people that worked in these companies.
The federal False Claims Act and many similar state laws pay handsome awards to whistleblowers that come forward and report wrongdoing. Stopping fraud is important – Medicare fraud alone costs taxpayers billions each year and also deprives services to those who are truly deserving of healthcare.
Geisinger Health System
- On July 17th, CMS imposed a $180,000 civil penalty against Geisinger Health System. The government made several findings about Geisinger including the company’s failure to properly manage its prescription drug program and failure to reach out to patients or doctors to get information necessary to make “appropriate clinical decisions.”
Moda Health Plan
- On July 17th, CMS fined Moda Health Plan $312,000. Like Geisinger, the government says that the company failed to properly manage its prescription drug program.
Cambia Health Solutions
- Cambia Health Solutions of Portland, Oregon was fined $254,000 on July 16th for failure to properly manage its prescription drug program and failure to reach out to patients or doctors to get information necessary to make “appropriate clinical decisions.”
Express Scripts Medicare
- This company was fined $334,00 for a variety of problems with the way they handled Medicare prescription drugs. We always take a keen interest in these type of violations as there is a risk that other more serious problems remain undiscovered.
Tufts Associated HMO
- Watertown, Massachusetts based Tufts Associated HMO was fined $137,000 in June. Once again, the fines relate to a series of audit findings in their Medicare prescription drug program. Although the fine is relatively small, pharmacy programs are at high risk for overbilling.
Independent Health Association Inc
- Buffalo, New York based Independent Health Association was fined $154,000 in April for Medicare prescription drug program problems.
Lifetime Healthcare Inc
- Lifetime Healthcare of Rochester, New York received a hefty $447,000 fine this April. Like all the other audit findings in this post, the violations relate to how they operate their drug program.
Simply Healthcare Plans
- This Miami based company was fined $253,000 earlier this spring for prescription drug program problems.
This list is not exhaustive and simply because a company is named in this post doesn’t mean they did anything wrong. Although the government made significant findings and issued millions of dollars in fines, each provider has the right to an appeal. We simply don’t know whether appeals have been filed and if so, the status of the case.
Once again, the sole purpose of this post is to seek former employees or would be whistleblowers from each of these providers. Whether you have “original source” information about these companies or simply have information you feel is valuable, give us a call. Of course, we welcome calls from anyone with knowledge of significant Medicare fraud.
And remember, to receive a cash award, you must have original source information about a fraud against the government or to a tax supported agency.