Qui tam cases often reap sizeable awards for the government and the Whistleblower. For instance, in FY 2005, as a result of a qui tam suit filed by Ven-A-Care of Florida Keys, a small home-infusion company, GlaxoSmithKline paid the federal government $140 million to settle allegations of fraudulent drug pricing and marketing that resulted in the submission of inflated claims to Medicare, Medicaid, and other federally funded programs.
The US alleged that Glaxo reported inflated prices for Zofran and Kytril, drugs used primarily to reduce the negative side effects of radiation and other cancer treatments, knowing that those prices would be used by federal programs to set reimbursement rates. Glaxo used the artificial spread between the inflated prices and its customers' lower cost to purchase the drugs as a marketing tool.
In addition to the $140 million federal share of recovery, Glaxo also paid $10 million to reimburse state Medicaid funds.
In FY 2005, the DOJ opened 778 new civil health care fraud investigations, and had 1,334 civil investigations pending at the end of the fiscal year. In addition to these joint cases, USAOs are responsible in all other qui tam cases for investigating the relator's allegations and, where appropriate, litigating and or settling the case. In FY 2005, the DOJ filed complaints or intervened in 266 civil health care cases.
In a case of hospital fraud, HealthSouth Corporation paid $327 million to settle allegations of fraud against Medicare and other federal health care programs. The US charged that HealthSouth, engaged in three major schemes to defraud the government.
The first, involving $170 million of the settlement, resolved false claims for outpatient physical therapy services that were not properly supported by certified plans of care, administered by licensed therapists, or for one-on-one therapy as represented.
Another $65 million resolved charges that HealthSouth engaged in accounting fraud which resulted in overbilling Medicare on hospital cost reports and home office cost statements.
The remaining $92 million resolved allegations of billing Medicare for various unallowable costs, such as lavish entertainment and travel expenses incurred for company's annual administrators' meeting at Disney World and other claims.
The government initiated claims accounted for $251 million of the settlement, with the remaining $76 million paid out in four qui tam lawsuits.
HealthSouth also entered into a corporate integrity agreement with the HHS to prevent future misconduct.
In FY 2005, the Civil Division was allotted $15.459 million in funds to support civil health care fraud litigation. Civil Division attorneys pursue civil remedies, working closely with the USAOs, the FBI, the HHS, and other federal and state law enforcement agencies involving providers of health care services, supplies and equipment, as well as carriers and fiscal intermediaries, that defraud Medicare, Medicaid, TRICARE, the Federal Employee Health Benefit Program, and other government programs.
In FY 2005, the Division opened or filed 306 new health care fraud cases. In addition, the Civil Division also pursued 642 existing cases that remained open at the end of FY 2004.
The Civil Division litigates cases involving overcharging by hospitals, and other Medicare Part A providers; similar claims against suppliers under Medicare Part B; allegations involving state Medicaid programs; claims that doctors and others have been paid kickbacks to induce referrals of Medicare or Medicaid patients; claims of overpricing and illegal marketing of pharmaceuticals; and allegations that nursing homes have failed to provide necessary care to residents.
Among these are multi-district cases involving large health providers and suppliers that typically require coordination among federal agencies, USAOs, state Medicaid Fraud Control Units, and various other investigative organizations.
In one such case, as a result of allegations made against the Eisenhower Medical Center in Rancho Mirage, California in a qui tam lawsuit by a former employee, the Eisenhower Center paid $8 million to settle charges that it fraudulently overbilled federal health insurance programs.
Specifically, the lawsuit alleged that Healthcare Financial Advisors helped its hospital clients seek reimbursement for non-allowable costs and helped clients prepare two cost reports, one inflated to submit to Medicare, and a second one for internal use only that accurately reflected the amount of reimbursement the hospital should have received.
The US alleged that Glaxo reported inflated prices for Zofran and Kytril, drugs used primarily to reduce the negative side effects of radiation and other cancer treatments, knowing that those prices would be used by federal programs to set reimbursement rates. Glaxo used the artificial spread between the inflated prices and its customers' lower cost to purchase the drugs as a marketing tool.
In addition to the $140 million federal share of recovery, Glaxo also paid $10 million to reimburse state Medicaid funds.
In FY 2005, the DOJ opened 778 new civil health care fraud investigations, and had 1,334 civil investigations pending at the end of the fiscal year. In addition to these joint cases, USAOs are responsible in all other qui tam cases for investigating the relator's allegations and, where appropriate, litigating and or settling the case. In FY 2005, the DOJ filed complaints or intervened in 266 civil health care cases.
The first, involving $170 million of the settlement, resolved false claims for outpatient physical therapy services that were not properly supported by certified plans of care, administered by licensed therapists, or for one-on-one therapy as represented.
Another $65 million resolved charges that HealthSouth engaged in accounting fraud which resulted in overbilling Medicare on hospital cost reports and home office cost statements.
The remaining $92 million resolved allegations of billing Medicare for various unallowable costs, such as lavish entertainment and travel expenses incurred for company's annual administrators' meeting at Disney World and other claims.
The government initiated claims accounted for $251 million of the settlement, with the remaining $76 million paid out in four qui tam lawsuits.
HealthSouth also entered into a corporate integrity agreement with the HHS to prevent future misconduct.
In FY 2005, the Civil Division was allotted $15.459 million in funds to support civil health care fraud litigation. Civil Division attorneys pursue civil remedies, working closely with the USAOs, the FBI, the HHS, and other federal and state law enforcement agencies involving providers of health care services, supplies and equipment, as well as carriers and fiscal intermediaries, that defraud Medicare, Medicaid, TRICARE, the Federal Employee Health Benefit Program, and other government programs.
In FY 2005, the Division opened or filed 306 new health care fraud cases. In addition, the Civil Division also pursued 642 existing cases that remained open at the end of FY 2004.
The Civil Division litigates cases involving overcharging by hospitals, and other Medicare Part A providers; similar claims against suppliers under Medicare Part B; allegations involving state Medicaid programs; claims that doctors and others have been paid kickbacks to induce referrals of Medicare or Medicaid patients; claims of overpricing and illegal marketing of pharmaceuticals; and allegations that nursing homes have failed to provide necessary care to residents.
Among these are multi-district cases involving large health providers and suppliers that typically require coordination among federal agencies, USAOs, state Medicaid Fraud Control Units, and various other investigative organizations.
In one such case, as a result of allegations made against the Eisenhower Medical Center in Rancho Mirage, California in a qui tam lawsuit by a former employee, the Eisenhower Center paid $8 million to settle charges that it fraudulently overbilled federal health insurance programs.
Specifically, the lawsuit alleged that Healthcare Financial Advisors helped its hospital clients seek reimbursement for non-allowable costs and helped clients prepare two cost reports, one inflated to submit to Medicare, and a second one for internal use only that accurately reflected the amount of reimbursement the hospital should have received.
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