Category: Overpayments

DOJ Announces Settlement with Home-Health Services Company Over FCA Kickback and Overbilling Allegations

The Department of Justice recently announced that it resolved two civil lawsuits filed under the qui tam, or whistleblower, provisions of the False Claims Act to the tune of nearly $4 million. The suits alleged that a suburban Chicago diagnostics company, SNAP Diagnostics, LLC, that provides home testing for sleep disorders was defrauding Medicare and four other federal health care programs through kickbacks and unnecessary...

Enforcement Standards Tighten on Private Insurers: Sutter Health Settles for $90 Million Following Dispute With DOJ

On August 30, 2021, the Department of Justice (“DOJ”) announced that Sutter Health and several of its affiliated entities (“Sutter”) agreed to pay a total of $90 million to settle allegations that Sutter violated the False Claims Act (“FCA”), 31 U.S.C. §§ 3729-3733, by “knowingly submitting inaccurate information about the health status of beneficiaries enrolled in Medicare Advantage Plans.”  Sutter Health and Affiliates to Pay...

Sutter Health LLC Pays $30 Million to Settle Alleged Overpayment of Medicare Advantage Funds, but Faces Similar Allegations in Separate Qui Tam

On April 12, 2019, the U.S. Department of Justice announced Sutter Health LLC—along with its affiliates Sutter East Bay Medical Foundation, Sutter Pacific Medical Foundation, Sutter Gould Medical Foundation, and Sutter Medical Foundation—would pay $30 million to settle allegations they provided inaccurate information about Medicare Advantage Plan beneficiaries in order to receive inflated payments. The settlement stems from a coordinated effort between the U.S. Department...

Another Qui Tam Suit Alleging a Scheme to Defraud by Reporting Inflated Drug Prices Survives Motion to Dismiss

Within the last five years, district courts in the Seventh Circuit have repeatedly denied motions to dismiss qui tam lawsuits brought under the FCA that allege a scheme to defraud government health programs by reporting inflated “usual and customary” prices for prescription drugs. By contrast, at least one district court in the Sixth Circuit recently granted such a motion under Rule 9(b). On March 7,...

Construction Subcontractor Settles FCA Allegations for $2.8 Million

A recent settlement illustrates the broad reach of the FCA and the substantial liability that “mere retention” of an overpayment can impose on contractors several steps removed from a government contract.  The dispute involved alleged overpayments made to Bartlett Holdings Inc. (d/b/a BHI Energy/Sun Technical Services) during its performance as a subcontractor on a Federal project.  Bartlett is a supplier of radiological protection services and...

Former Medicaid Auditor for D.C. Government Permitted to Proceed with FCA Retaliation Claim

The Federal District Court for the District of Columbia recently ruled that a former director of Medicaid audits in Washington D.C. can proceed with retaliation claims alleging he was fired for trying to stop his former bosses from covering up $100 million in improper payments to medical providers. Paul Hicks was hired by District of Columbia’s Office of the Inspector General (“OIG”) as an auditor in...

Failure to Disclose Best Pricing: Pharmaceutical Companies Settle FCA Claims for $784 Million

The Department of Justice announced late last month that pharmaceutical manufacturers Wyeth and Pfizer would pay $784 million to resolve a False Claims Act investigation and qui tam lawsuit arising from Wyeth’s failure to disclose its best pricing of drugs to the government.  The case was brought under the FCA’s qui tam provisions; the relators’ share of the recovery is nearly $100 million. The case...

District Court Rejects Government’s FCA Claim Seeking Return of Retained Benefits; Decides that Agency Policy Guidance Did Not Create an “Obligation” Under the Act

In an opinion issued earlier this month, the United States District Court for the Eastern District of Oklahoma refused to impose False Claims Act liability on a defendant who retained and invested his mother’s Social Security benefits after she went missing. The case adds to the growing body of law on the word “obligation” as it is used in the FCA; it also showcases the...

CMS Finalizes Rule Requiring Healthcare Providers to Return Overpayments

Late last week, the Centers for Medicare & Medicaid Services (CMS) published its final rule regulating how healthcare providers must report and return overpayments. This rule implements the Affordable Care Act’s requirement that healthcare providers who receive an overpayment from Medicare return the overpayment within 60 days of its identification. Overpayments not returned within the 60-day limit become “obligations” to the Federal government within the...

DOJ Settles “First of its Kind” FCA Suit Involving Retention of Overpayments

On August 3, the Department of Justice announced the first False Claims Act settlement of a case involving a health-care provider’s alleged failure to investigate, identify and refund overpayments from government programs, including Medicare, Medicaid and TRICARE.  Such claims (and settlements) may become more common given the recent amendments to the FCA in 2010, which provide that Medicare and Medicaid overpayments be reported and returned within “60...