NEW ORLEANS - A federal judge in Louisiana on Oct. 13 sentenced a woman to one year and one day in prison and ordered her to pay $536,724 in restitution after she pleaded guilty to one count of health care fraud for misappropriating Medicaid funds received by a pediatric clinic where she worked for her to pay off unauthorized charges on a business credit card (United States of America v. Monica Sylvest, No. 17cr24, E.D. La.).
NEW YORK - After finding that an insurer did not improperly deny coverage for continued treatment of an insured's anorexia nervosa in violation of the Employee Retirement Income Security Act, the Second Circuit U.S. Court of Appeals on Oct. 2 affirmed a court's ruling that the insurer's decision to cease coverage was based on the substantial evidence (Elizabeth W. v. Empire Healthchoice Assurance Inc., et al., No. 16-3463, 2nd Cir., 2017 U.S. App. LEXIS 19099).
FRANKFORT, Ky. - A federal judge in Kentucky on Sept. 29 affirmed a jury's decision to convict two physicians who owned addiction clinics, as well as the partial owners of a laboratory that conducted screenings for urine drug tests of 17 counts of aiding and abetting one another to commit health care fraud, finding that the evidence was sufficient to support the verdict and that the jury's conclusion was not manifestly unjust (United States of America v. Robert L. Bertram, M.D., et al., No. 15-cr-14-GVFT-REW, E.D. Ky., 2017 U.S. Dist. LEXIS 160884).
SAN DIEGO - Allegations that an emergency health care provider touted its compassion toward those with gender dysphoria and then repeatedly referred to a transgender boy as female support his mother's Patient Protection and Affordable Care Act (ACA) and California unfair competition law claims, a federal judge in California held Sept. 27 (Katharine Prescott, et al. v. Rady Children's Hospital - San Diego, No. 16-2408, S.D. Calif., 2017 U.S. Dist. LEXIS 160259).
BILLINGS, Mont. - A Montana federal judge on Sept. 20 granted a disability claimant's motion for summary judgment after determining that Montana's mental health parity law requires the plan to provide the claimant with the same benefits for her mental illness as it would if her disability were physical (Theresa Sand-Smith v. Liberty Life Assurance Company of Boston, No. 17-0004, D. Mont., 2017 U.S. Dist. LEXIS 153217).
SHERMAN, Texas - A Texas federal judge on Sept. 19 refused to dismiss a plaintiff's breach of fiduciary claims arising out of a health care plan's denial of coverage for autism treatments because the fiduciary claims are not disguised benefits claims and the plaintiff alleged sufficient facts to support the breach of fiduciary claims (Amy Whitley, et al. v. Dr Pepper Snapple Group Health Plan, et al., No. 17-47, E.D. Texas, 2017 U.S. Dist. LEXIS 152417).
SAN FRANCISCO - In a motion seeking interlocutory review, an insurer argues that whether the Patient Protection and Affordable Care Act (ACA) requires an insurer to provide access to lactation services or merely forbids financial barriers to obtaining such services is exactly the type of question the Ninth Circuit U.S. Court of Appeals should address and, in an answer to the complaint filed Sept. 19 in a California federal court, the insurer says the plaintiffs' fail to state a claim under either the Employee Retirement Income Security Act (ERISA) and the ACA on which relief can be based (Rachel Condry, et al. v. UnitedHealth Group Inc., et al., No. 17-183, N.D. Calif.).
TRENTON, N.J. - A federal judge in New Jersey on Sept. 19 struck defenses submitted via email by three defendants accused by Government Insurance Co., GEICO Indemnity Co., GEICO General Insurance Co. and GEICO Casualty Co. (collectively GEICO) of submitting approximately $3.3 million in false insurance claims, ruling that emails to counsel are not the proper procedure for responding to a lawsuit (Government Employees Insurance Company, et al. v. Hamilton Health Care Center, P.C., et al., No. 17-0674, D. N.J., 2017 U.S. Dist. LEXIS 151772).
HOUSTON - A health plan beneficiary is owed full coverage for a gastric bypass surgery and a follow-up surgery and care required after she experienced complications, a Texas federal judge ruled Sept. 14, finding that the beneficiary's evidence that she has experienced nausea and vomiting placed her within the health plan's exception to its weight loss surgery exclusion (Karen A. Rittinger v. Health Alliance Life Insurance Company, et al., No. 16-639, S.D. Texas, 2017 U.S. Dist. LEXIS 149394).
NEWARK, N.J. - A firm of pediatric doctors can pursue allegations that a skilled nursing and rehabilitation facility violated the False Claims Act, the New Jersey False Claims Act (NJFCA) and the New York False Claims Act (NYFCA) for unlawfully billing Medicare and Medicaid as primary payers rather than a patient's private insurance company, a federal judge in New Jersey ruled Sept. 18, finding that the firm sufficiently stated claims under Federal Rule of Civil Procedure 12(b)(6) (United States of America v. Wanaque Convalescent Center, et al., No. 14-6651, D. N.J., 2017 U.S. Dist. LEXIS 150566).
NEW ORLEANS - A woman was properly convicted and sentenced to 140 months in prison for illegally billing Medicare more than $250,000 for medical equipment for beneficiaries that was not medically necessary, a Fifth Circuit U.S. Court of Appeals panel ruled Sept. 13, finding that she was deliberately ignorant of her scheme (United States of America v. Tracy Richardson Brown, No. 16-30933, 5th Cir.).
NEW ORLEANS - A Fifth Circuit U.S. Court of Appeals panel on Aug. 17 affirmed a jury's verdict convicting a man of committing health care fraud and paying and receiving kickbacks for approving patients for home health care when they did not need such treatment (United States v. Warren Dailey, No. 16-20517, 5th Cir., 2017 U.S. App. LEXIS 15595).
ST. LOUIS - A federal judge on Aug. 15 sentenced a podiatrist to 90 months in prison and ordered him to pay $6.9 million in restitution for fraudulently billing Medicare for services that were not rendered (United States v. Yev Gray, No. 15cr464, E.D. Mo.).
HOUSTON - A registered nurse who owned two home health care companies was found guilty on Aug. 10 by a federal jury in Texas of one count of conspiracy to commit health care fraud and four counts of health care fraud for her role in a $20 million Medicare fraud scheme (United States v. Evelyn Mokwuah, No. 16cr254, S.D. Texas).
GREENVILLE, Miss. - The U.S. Department of Justice announced Aug. 10 that a federal judge in Mississippi has sentenced a doctor to 39 months in prison and ordered him to pay $1.9 million in restitution to the Medicare program for referring patients to hospice care when such treatment was not necessary (United States v. Nathaniel Brown, No. 16cr74, N.D. Miss.).
SAN FRANCISCO - A Ninth Circuit U.S. Court of Appeals panel on Aug. 10 held that two medical assistants who filed a qui tam lawsuit under the False Claims Act (FCA) against a podiatrist they worked for could not intervene in a criminal forfeiture action brought by the federal government seeking $1.2 million for false billing to Medicare because the employees lacked standing (United States v. Neil A. Van Dyck, et al., No. 16-10160, 9th Cir., 2017 U.S. Dist. LEXIS 14780).
CHICAGO - A federal judge in Illinois on Aug. 7 granted a motion for summary judgment filed by a podiatry firm and its owner that are accused by a former employee of violating the Illinois Insurance Claims Fraud Protection Act (IICFPA) and illegally destroying medical records, finding that there was not enough evidence to show that the procedures the firm billed to Medicare were not medically necessary and that the defendants were not aware of the lawsuit at the time the records were shredded (James Youn, M.D. v. Keith D. Sklar, et al., No. 10 CV 5583, N.D. Ill., 2017 U.S. Dist. LEXIS 124394).
SEATTLE - A federal judge in Washington on July 27 denied a chiropractor and his practice's motion to amend counterclaims against State Farm Mutual Automobile Insurance Co., finding that the insurer had sufficient reason to report his billing practices to the National Insurance Crime Bureau (NICB) (State Farm Mutual Automobile Insurance Company v. Peter J. Hanson, P.C. d/b/a Hanson Chiropractic, et al., No. C16-1085RSL, W.D. Wash., 2017 U.S. Dist. LEXIS 118045).
ANN ARBOR, Mich. - A Native American tribe cannot pursue claims that its health care plan administrator violated the Employee Retirement Income Security Act (ERISA) by failing to charge the tribe Medicare-like rates for contracted services at a hospital because the tribe waited too long to sue, a Michigan federal judge held July 21 (Grand Traverse Band of Ottawa and Chippewa Indians, et al. v. Blue Cross Blue Shield of Michigan v. Munson Medical Center, No. 5:14-cv-11349, E.D. Mich., 2017 U.S. Dist. LEXIS 113759).
PHILADELPHIA - A Third Circuit U.S. Court of Appeals panel ruled July 19 that administrators of an outpatient surgical facility cannot be found liable for violating Pennsylvania's insurance fraud statute because the anti-kickback provision of the statute applies only to health care providers (Aetna Life Insurance Company v. Huntingdon Valley Surgery Center, et al., No. 16-1468, 3rd Cir., 2017 U.S. App. LEXIS 12971).
COLUMBIA, S.C. - A failed Patient Protection and Affordable Care Act (ACA) co-operative insurer's liquidator should file his lawsuit challenging a federal loan repayment demand in the U.S. Court of Federal Claims, the government says in a July 19 motion filed in South Carolina federal court (Raymond G. Farmer v. United States of America, et al., No. 17-cv-00956, D. S.C.).
CINCINNATI - Three companies and their executives have agreed to pay $19.5 million for allegedly violating the False Claims Act (FCA) by billing Medicare for medically unnecessary rehabilitation therapy and hospice services, the U.S. Department of Justice announced July 18 (United States, ex rel. Trakhter v. Provider Services Inc., et al., No. 11-CV-217, United States, ex rel. Goodwin, et al. v. Brian Colleran, et al.., No. 11-CV-935, S.D. Ohio.).
BAY CITY, Mich. - A health care plan administrator owes a Michigan Indian tribe more than $8.4 million for violating the Employee Retirement Income Security Act by charging hidden administrative fees for the tribe's employee benefit program but is not liable for any alleged damages related to the tribe's separate health care plan for all of its members, even though some are also employees, a federal judge held July 14 (Saginaw Chippewa Indian Tribe of Michigan, et al. v. Blue Cross Blue Shield of Michigan, No. 1:16-cv-10317, E.D. Mich., 2017 U.S. Dist. LEXIS 109366).
WASHINGTON, D.C. - A trio of women successfully allege standing in their class action claiming that an insurer improperly charged them for out-of-network lactation services in violation of the Patient Protection and Affordable Care Act (ACA), a federal judge in the District of Columbia held July 17 (Lindsay Ferrer, et al. v. CareFirst Inc., et al., No. 16-2162, D. D.C., 2017 U.S. Dist. LEXIS 110304.)
NEW ORLEANS - The owners of two psychological services companies were sentenced by a federal judge in Louisiana for their roles in a $25.2 million Medicare fraud scheme, the U.S. Department of Justice announced July 14 (United States of America v. Rodney Hesson, et al., No. 15-cr-152, E.D. La.).