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Georgia Optometrist Settles Allegations of False Billing and Upcoding for $275,000

Georgia-based optometrist Jeffrey Sponseller has agreed to pay settlement claims of $275,000 after pleading guilty to illegal conduct committed against the state and federal Medicaid and Medicare programs.
Image source: Wikimedia Commons

State and federal guidelines impose strict billing requirements when it comes to routine eye care. Unlike many private insurance plans, coverage under Medicare or Medicaid generally provides reimbursement for vision services, provided the optometrist engages in medically necessary procedures.

Today we’ll review a whistleblower case filed in 2014 against optometrist Jeffrey Sponseller and his practice Eye Care One. This case alleged the Georgia-based optometrist of fraudulently billing state and federal programs for the reimbursement of services that were not necessary or that the patient did not actually receive. Sponseller and Eye Care One pleaded guilty to the accusations, and recently agreed to pay $275,000 to settle the claims against them.

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Walter Investment Management Corporation Settles Mortgage Fraud Case for $29 Million

walter investments mortgage fraud

Walter Investments has agreed to pay $29 million to settle allegations it falsely certified residential reverse mortgages as compliant with HUD guidelines.
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In yet another mortgage fraud case, Walter Investment Management Corporation (Walter Investment) has agreed to pay over $29 million to resolve allegations it falsely certified residential home mortgages under the Department of Housing and Urban Development’s (HUD) Home Equity Conversion Mortgage (HECM)[1] program. The alleged scheme was uncovered following a whistleblower lawsuit filed by a former executive of Walter Investment. The whistleblower, in exchange for his willingness to expose the fraud, will receive $5.15 million under the False Claims Act’s qui tam provisions.

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Parsons Infrastructure & Technology Group Settles Allegations of Contractor Fraud for $3.8 Million

Contractor fraud at Savannah River Site

Contracting giant Parsons Infrastructure & Technology Group has agreed to pay nearly $4 million to settle allegations it submitted false claims for reimbursement under several federal contracts involving the Savannah River Site.
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The Savannah River Site is a nuclear facility1 built in the 1950s and maintained by the federal government via several contracts with engineering and environmental firms. According to its mission statement, the site is “a key Department of Energy (DOE) industrial complex responsible for environmental stewardship, environmental cleanup, waste management and disposition of nuclear materials. More specifically, SRS processes and stores nuclear materials in support of national defense and U.S. nuclear nonproliferation efforts.”

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  1. Savannah River Site Fact Sheet, http://www.srs.gov/general/news/factsheets/srs.pdf

K-Mart Pharmacy Accused of Defrauding Medicare; Settles for $1.4 Million

medicare fraud

Retail chain K-Mart has agreed to settle allegations it intentionally defrauded Medicare via customer coupons and discounts.
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Much like healthcare providers are prohibited from providing kickbacks to  doctors and patients, pharmacies are likewise prohibited from inducing potential customers by offering financial incentives to choose one dispensary over another. In essence, the government seeks to ensure Medicare enrollees are free to choose the pharmacy of their liking without any outside influence – including discounts not offered to the public as a whole.

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The Growing Problem of Data Falsification by Overseas Drug Manufacturers

The Indian generic drug market is becoming increasingly synonymous with sub-par quality and substandard regulation – which has resulted in possible drug resistance and the spread of disease.
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In yesterday’s post, we reviewed a controversial phenomenon plaguing the international drug market involving the production of substandard generic medications in India. More specifically, we looked at how patients in America and worldwide could face harm by taking drugs manufactured by companies like Ranbaxy, as studies have revealed that key ingredients are either insufficient or missing altogether. In many nations, the fear of drug resistance has been aggravated by the use of these medications, particularly with regard to conditions like aggressive tuberculosis.

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Potential Dangers Lurking in Generic Drugs Manufactured in India

In his recent article entitled Beware of ‘Made in India’ Medicine, whistleblower Dinesh Thakur explores the growing trend of clinical data falsification by generic drug makers.
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Over the next two posts, we’ll explore a growing international problem involving the safety of generic drugs produced overseas. Namely, generic medications produced in India – including those manufactured by False Claims Act offender Ranbaxy – are becoming more and more problematic, due in part to the alleged falsification of clinical testing data relied upon by other nations to ensure patient safety. Moreover, when challenged by whistleblowers and others within the medical community, international regulators engage in unproductive political maneuvers and other avoidance tactics as opposed to conducting transparent investigations to get to the root of the issue.

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Quest Diagnostics to Pay $1.79 Million to Settle Fraud Claims

A New Jersey-based diagnostic clinical laboratory has agreed to pay $1.79 million to settle claims it defrauded Medicare.
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Under the guidelines of Medicare Part B, enrollees are entitled to coverage for medically necessary and essential diagnostic services, including bloodwork, x-rays, and similar imaging examinations. If a provider fails to adhere to the Medicare guidelines, it could quickly face liability under the False Claims Act for unlawfully billing the government in violation of established regulations.

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New York Attorney General Announces $8 Million Settlement Over Unlicensed Detox Programs

NY AG settlement

New York Attorney General Eric Schneiderman recently announced a historic settlement with several medical companies engaging in alleged illegal kickbacks.
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Following a lengthy investigation by both the state of New York’s Medicaid Fraud Control Unit and the U.S. Attorney’s Office for the Eastern District of New York, several medical corporations operating in the state have agreed to pay $8 million to settle allegations of fraud against Medicaid and Medicare.

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Nuances of Liability: Conditions of Payment vs. Conditions of Participation Under the False Claims Act

Courts have taken different approaches when faced with ‘condition of payment’ claims versus ‘condition of participation’ under the False Claims Act.
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In yesterday’s post, we reviewed two concepts that often serve as the basis of a whistleblower’s complaint under the False Claims Act. The first is known as a condition of payment violation, which occurs when a provider knowingly submits a claim for reimbursement to Medicare or Medicaid in violation of an administrative code or regulation, upon which payment is explicitly conditioned. The second is known as a condition of participation, which pertains more generally to the safety and protocol measures required of participating Medicare and Medicaid doctors and specialists.

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Understanding Conditions of Payment vs. Conditions of Participation

As practitioners of False Claims Act litigation, our team understands the highly-nuanced areas of both pre-conditions for payment and conditions for participation – both of which can trigger liability if not followed.

As practitioners of False Claims Act litigation, our team understands the highly-nuanced areas of both pre-conditions for payment and conditions for participation – both of which can trigger liability if not followed.

The False Claims Act is a unique and nuanced law that has been in effect since the 1800s. Since then, it has undergone several amendments and has become an integral part of the government’s fight against wasteful healthcare and defense fraud. One of the most highly-contested issues within False Claims Act cases is actually whether the Act applies at all, or if the defendant’s alleged misconduct merely amounts to traditional common law fraud or negligence.

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