Two of the key healthcare related enforcement actions from the last two weeks involved lab tests that were either medically unnecessary or not even provided.
In the first case, announced by the U.S. Department of Justice (DOJ) on Oct. 20, an Ohio doctor settled False Claims Act (FCA) violations for $720,000. Mangesh Kanvinde, MD, also agreed to a 15-year exclusion from federal healthcare programs. Kanvinde was allegedly involved in a scheme in which he ordered medically unnecessary genetic tests and durable medical equipment (DME). The specific genetic tests related to a person’s risk for developing cancer, a type of test that has become a particularly ripe area for fraud recently.
According to the DOJ, Kanvinde allegedly:
- Knowingly conspired to submit or submitted false claims to Medicare
- “Had improper financial arrangements with temporary physician staffing agencies and telehealth companies” to order DME and genetic testing “items and services”
- Received illegal kickbacks for the above products and services, which he knew were medically unnecessary
- Did not have a physician-patient relationship with the Medicare beneficiaries he was prescribing for
In addition to the above settlement, Kanvinde will also make additional payments based on his income over the next five years, the DOJ said in its statement.1
In the second scheme, announced Oct. 27, a clinical lab owner and his co-conspirators billed and received payment from Medicare for millions of dollars’ worth of lab tests that were never ordered by physicians or provided to the patients listed on the bills, the DOJ stated.
Billy Joe Taylor and his partners in crime either controlled or owned five different clinical labs in various locations across the US, including Imaginus Diagnostic Laboratory LLC in Spiro, Oklahoma; Beach Tox LLC in Torrance, California; Nations Laboratory Services LLC in Tecumseh, Oklahoma; Corrlabs LLC in Southern Pines, North Carolina; and Vitas Laboratory LLC in Barling, Arkansas.
Taylor pleaded guilty to one count of money laundering and one count of conspiracy to commit healthcare fraud for his role in submitting more than $130 million in false claims for these labs, of which he and his co-conspirators received $38 million from Medicare. He will be sentenced in about four months and faces up to 20 years in prison for his crimes, the DOJ stated.2
Other Recent Healthcare-Related Enforcement Actions
Oct. 18: Home health provider Carter Healthcare LLC, along with its affiliates Carter-Florida and CHC Holdings and its president and chief operations officer, settled FCA allegations for $7.175 million. The company allegedly “knowingly and improperly” billed Medicare for medically unnecessary therapy and also upcoded patients’ diagnoses in order to receive higher reimbursement, the DOJ stated.3
Oct. 26: A New York state hospital settled improper Medicaid and Medicare billing allegations, which were brought forward in a qui tam whistleblower lawsuit, for $98,694.36. In the first case of improper billing, Oswego Hospital allegedly billed both healthcare programs for mental healthcare services provided by an unsupervised licensed master social worker (LMSW). In the second case, the hospital was accused of not providing the proper documentation for similar services provided by another LMSW that it billed to Medicaid.4