U.S.-CVS SUBSIDIARY REACH $5 MILLION SETTLEMENT RELATED TO FASLE PRICING

FROM: U.S. DEPARTMENT OF JUSTICE
Monday, October 15, 2012

CVS Subsidiary, RxAmerica, Reaches $5 Million Settlement with US for Allegedly Submitting False Pricing Relating to the Company’s Medicare Part D Plan

In one of the first False Claims Act settlements involving Medicare’s Prescription Drug Program, known as Part D, RxAmerica LLC. has entered into a civil settlement agreement with the United States in which it has agreed to pay the government $5.25 million to resolve allegations that it made false submissions to the Centers for Medicare & Medicaid Services (CMS), the Justice Department announced today. RxAmerica, a wholly-owned subsidiary of CVS Caremark Corporation, provides prescription drug benefits to Medicare beneficiaries pursuant to a prescription drug plan.

The Medicare program offers Part D participants prescription drug coverage. For Medicare participants to obtain this drug coverage, they must join a Medicare-approved plan, often referred to as a Part D plan. Medicare Part D plans can vary in both the drugs that they cover, the amount they reimburse for those drugs, and the deductibles and co-pays they require their participants to pay.

To assist participants to choose a Part D plan that minimized their out-of-pocket costs, CMS offered a web-based tool called Plan Finder, which allowed Medicare Part D beneficiaries to determine estimated prescription drug prices for each Medicare Part D plan that the beneficiary considered for enrollment. CMS obtained the pricing information that is contained on Plan Finder from data submitted to CMS by each Part D Plan sponsor.

The United States alleged that during the period Jan. 1, 2007, to Dec. 31, 2008, RxAmerica made false submissions to CMS regarding prices for certain generic prescription drugs used for Plan Finder, despite certifying to CMS that it would submit accurate pricing data for Plan Finder. As a result, the government alleged that RxAmerica received Medicare Part D payments for claims for the covered drugs at prices that in some cases were significantly higher than the pricing data RxAmerica submitted to CMS for use on Plan Finder.

"The Department of Justice is committed to protecting the Medicare drug prescription program against all types of misconduct," said Stuart F. Delery, Acting Assistant Attorney General for the Justice Department's Civil Division. "As today's settlement demonstrates, we will ensure that Medicare Part D sponsors submit accurate drug pricing information, to ensure the integrity of the Medicare Part D program and to protect the beneficiaries who participate in the program."

"The health care choices facing Americans are complicated enough without patients being misinformed and forced to select a Part D plan based on false data. Those navigating our Medicare system deserve accurate information so they can make informed choices and obtain the benefits to which they are entitled. The Medicare system deserves honest input from plan sponsors, so it can continue to safeguard taxpayer dollars. Nothing less will suffice," stated Loretta Lynch, U.S. Attorney for the Eastern District of New York. "This case exemplifies our continuing dedication to combating all types of alleged health care fraud that can eat away at our precious public health care dollars."

" RxAmerica was charged with advertising false drug prices to Medicare Part D enrollees," said Daniel R. Levinson, Inspector General of the Department of Health and Human Services. "Protecting people in government health programs from those seeking to profit by misrepresenting goods and services is one of our top law enforcement priorities."

Today’s settlement resolves allegations made in two separate complaints against RxAmerica filed under the False Claims Act’s qui tam or whistleblower provisions, which permit a private individual to file suit for false claims to the United States and share in any recovery. The first complaint, U.S. ex rel. Doe v. RxAmerica, was filed in the United States District Court of the Eastern District of New York in November 2008. The second complaint, U.S. ex rel. Hauser v. CVS Caremark Corp. and RxAmerica, was filed in the United States District Court for the Western District of North Carolina in June 2009. The two cases were consolidated in the Eastern District of New York in November 2011.

This resolution is part of the government’s emphasis on combating health care fraud and another step for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced by Attorney General Eric Holder and Kathleen Sebelius, Secretary of the Department of Health and Human Services in May 2009. The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation. One of the most powerful tools in that effort is the False Claims Act, which the Justice Department has used to recover over $10 billion since January 2009 in cases involving fraud against federal health care programs. The Justice Department’s total recoveries in False Claims Act cases since January 2009 are over $13.8 billion.

The Federal Trade Commission reached an agreement with CVS, RxAmerica’s parent corporation, earlier this year in which CVS agreed to pay $5 million to resolve allegations relating to RxAmerica’s inaccurate Plan Finder submissions from late 2007 through 2008. The resolution from the FTC’s settlement is being used to compensate beneficiaries.

The investigation in this matter was handled by the Department of Justice’s Civil Division, the U.S. Attorney’s Office for the Eastern District of New York, HHS-OIG and CMS. The claims resolved by this settlement are allegations only, and there has been no admission of liability by RxAmerica or CVS.

COMPANY SETTLES FALSE CLAIMS TO MEDICARE CASE

FROM:  JUSTICE DEPARTMENT
Friday, April 13, 2012
Ammed Direct Llc to Pay $18 Million to United States and Tennessee to Resolve False Claims Allegations
AmMed Direct LLC has agreed to pay the United States and the state of Tennessee $18 million plus interest to settle allegations that it submitted false claims to Medicare and Tennessee Medicaid (TennCare), the Justice Department announced today.   Under the agreement, AmMed will pay $17,560,997 to the United States and $439,003 to Tennessee.

The United States and Tennessee allege that, from September 2008 through January 2010, the Antioch, Tenn.-based company submitted false claims to Medicare and TennCare for diabetes testing supplies, vacuum erection devices and heating pads.   The United States and Tennessee asserted that AmMed widely advertised free cookbooks in order to induce Medicare beneficiaries to contact AmMed or its hired telemarketing firm.   Once AmMed confirmed that a beneficiary was covered by Medicare, AmMed representatives improperly attempted to sell the beneficiary supplies that would be paid for by Medicare.   Medicare rules prohibit medical businesses from making unsolicited telephone contact with beneficiaries to sell them their products, unless specific exceptions apply.

The United States and Tennessee further alleged that, as a result of AmMed’s improper marketing, many Medicare beneficiaries who called AmMed to receive the advertised free cookbooks returned their diabetic supplies to AmMed.   AmMed, however, failed to timely refund the money to Medicare or TennCare.   Rather, AmMed allowed the unpaid refunds to accrue from September 2006 until January 2010.   Prior to learning of the United States’ and Tennessee’s investigation, AmMed disclosed to the Medicare Administrative Contractors its failure to refund monies for returned supplies and began paying the refunds to Medicare and TennCare.

“Government health care programs have in place important rules that prohibit suppliers from improperly contacting beneficiaries regarding their products,” said Stuart F. Delery, Acting Assistant Attorney General for the Justice Department’s Civil Division.   “The Department of Justice is committed to ensuring that companies that bill government health care programs abide by those rules.”

 “Enforcement of the False Claims Act remains a top priority of this office,” said Jerry E. Martin, U.S. Attorney for the Middle District of Tennessee.   “All Medicare providers must comply with Medicare rules for reimbursement.   The U.S. Attorney’s Office for the Middle District of Tennessee will continue to devote the resources necessary to vigorously protect taxpayers’ interests and aggressively pursue fraud and abuse.”

 “We are grateful for the hard work and cooperation of our state and federal agencies in this case,” said Tennessee Attorney General Bob Cooper. “Working to stop healthcare fraud is a major priority for all of us because ultimately everyone pays for this kind of theft.”

The allegations arose from a lawsuit brought under the qui tam, or whistleblower, provisions of the False Claims Act, which permit private citizens with knowledge of false claims against the government to bring an action on behalf of the United States and to share in any recovery.   The qui tam action was filed in 2009 in federal district court in Nashville, Tenn., by former AmMed Direct employee Bryan McNeese.   The relator will receive approximately $2.88 million as his share of the settlement proceeds.

This resolution is part of the government’s emphasis on combating health care fraud and another step for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced by Attorney General Eric Holder and Kathleen Sebelius, Secretary of the Department of Health and Human Services in May 2009.   The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation.   One of the most powerful tools in that effort is the False Claims Act, which the Justice Department has used to recover more than $6.7 billion since January 2009 in cases involving fraud against federal health care programs.   The Justice Department’s total recoveries in False Claims Act cases since January 2009 are over $9 billion.

The case was investigated by the Department of Health and Human Services- Office of Inspector General (HHS-OIG), the U.S. Attorney’s Office for the Middle District of Tennessee and the Tennessee Attorney General’s Office.   The Justice Department’s Civil Division monitored the investigation.

RADIATION ONCOLOGY PRACTICE PAYS $3,8 MILLION TO SETTLE FALSE CLAIMS CASE

FROM U.S. DEPARTMENT OF JUSTICE
Tuesday, April 3, 2012
Georgia-Based Radiation Oncology Practice to Pay $3.8 Million to Settle False Claims Act Case
WASHINGTON – Radiotherapy Clinics of Georgia LLC, a radiation oncology practice, and its affiliates RCOG Cancer Centers LLC, Physician Oncology Services Management Company LLC, Frank A. Critz, M.D. and Physician Oncology Services L.P. (collectively, RCOG) agreed to pay $3.8 million to settle claims that they violated the False Claims Act, the Justice Department announced today.  RCOG, which is located in Decatur, Ga., allegedly billed Medicare for medical treatment that they provided to prostate cancer patients in excess of those permitted by Medicare rules and for services that were not medically necessary.
           
The civil settlement resolves complaints filed by two whistleblowers, called relators, under the qui tam, or whistleblower, provisions of the False Claims Act by a former employee and a former doctor who both worked for RCOG.  The government alleged that RCOG overbilled Medicare for port films (X-ray images of the treatment area) and for simulations (the process by which radiation treatment fields are defined, filmed and marked on the skin in preparation for personalized radiation therapy).  Additionally, it was alleged that the practice overbilled Medicare for physics consults (production of complete special consultative reports for an individual patient) and for pre-plans ordered by Dr. Critz that were not medically necessary and/or never reviewed by the doctor.

“Protecting the integrity of the Medicare program, which over 47 million individuals rely on for their medical care, is one of the department’s highest priorities.  Health care providers are put on notice that they must bill only for medically appropriate care” said Stuart F. Delery, Acting Assistant Attorney General for the Justice Department’s Civil Division.

The complaints, which were filed separately by the two relators, were consolidated into the case captioned United States ex rel. R. Jeffrey Wertz and Rebecca S. Tarlton v. Radiotherapy Clinics of Georgia, LLC, et al., Civil Action No. 1:08-CV-2244, pending in the U.S. District Court for the Northern District of Georgia.  The relators, R. Jeffrey Wertz and Rebecca S. Tarlton, M.D., will receive $646,000 as their share of the proceeds.
Sally Quillian Yates, U.S. Attorney for the Northern District of Georgia, said, “This settlement demonstrates our office's continued commitment to stop Medicare fraud. Unfortunately, otherwise legitimate businesses continue to take advantage of federal healthcare programs for their private profit. We will not ignore these violations.”
“The OIG would like to remind providers that if they know a claim to be false, it is their responsibility to bill the claim properly,” said Derrick L. Jackson, Special Agent in Charge of the U.S. Department of Health and Human Services, Office of Inspector General (HHS-OIG) for the Atlanta region.  “The OIG will continue to hold companies like RCOG responsible for improper claims.”

Brian D. Lamkin, Special Agent in Charge, FBI Atlanta Field Office, stated: “The FBI continues to dedicate many investigative resources to the protection of the federally funded Medicare program from individuals who would attempt to divert these much needed funds through fraud.  The public is reminded that anyone with information regarding healthcare fraud, to include Medicare fraud, related activity should contact their nearest FBI field office.”

This resolution is part of the government’s emphasis on combating health care fraud and another step for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced by Attorney General Eric Holder and Kathleen Sebelius, Secretary of the Department of Health and Human Services in May 2009. The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation. One of the most powerful tools in that effort is the False Claims Act, which the Justice Department has used to recover more than $6.7 billion since January 2009 in cases involving fraud against federal health care programs. The Justice Department's total recoveries in False Claims Act cases since January 2009 are over $9 billion.
           

COMPANY THAT ALLEGEDLY ENCOURAGED DOCTORS TO SUBMIT INFLATED CLAIMS SETTLES WITH THE GOVERNMENT

The following excerpt is from the Department of Justice website:
Friday, March 23, 2012
Pennsylvania- Based Eusa Pharma (USA) Inc. to Pay U.S. $180,000 for Allegedly Submitting Inflated Claims to Medicare
WASHINGTON – EUSA Pharma (USA) Inc. has agreed to pay the United States $180,000 to resolve claims that it violated the False Claims Act by allegedly encouraging doctors to submit inflated claims to Medicare for imaging scans, the Justice Department announced today.  EUSA Pharma (USA) is headquartered in Langhorne, Pa.

The United States alleged that EUSA Pharma, which makes and sells ProstaScint, a radiopharmaceutical, advised health care providers to submit multiple claims for certain imaging scans performed following use of ProstaScint, after the Society of Nuclear Medicine informed the company that only one claim should be submitted for these scans.

“Today’s settlement demonstrates our commitment to ensuring that the Medicare Trust Fund is used to pay for necessary medical care and is not depleted as a result of marketing schemes intended to increase sales by inflating government reimbursements,” said Stuart F. Delery, Acting Assistant Attorney General of the Justice Department’s Civil Division.  “We will continue to hold accountable those who abuse public health care programs at the expense of taxpayers.”

Today’s settlement resolves a lawsuit filed by former EUSA Pharma employee Ann-Marie Williams under the qui tam, or whistleblower provisions, of the False Claims Act.  Under the False Claims Act, private citizens can bring suit on behalf of the United States and share in any recovery.  Ms. Williams will receive $30,600 as her share of the government’s recovery.

This resolution is part of the government's emphasis on combating health care fraud and another step for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced by Attorney General Eric Holder and Kathleen Sebelius, Secretary of the Department of Health and Human Services in May 2009.  The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation.  One of the most powerful tools in that effort is the False Claims Act, which the Justice Department has used to recover nearly $6.7 billion since January 2009 in cases involving fraud against federal health care programs.  The Justice Department's total recoveries in False Claims Act cases since January 2009 are over $8.9 billion.