Effective Compliance Reduces Kickbacks, Fraud and False Claims
Reviewing current settlements and fraud allegations and reviewing your own Compliance and Internal Auditing and Investigation processes is something the Office of Inspector General (OIG) expects from health care organizations.? Also, reviewing the OIG Work Plan, Special Fraud Alerts are part of the responsibility of the Compliance Office and your Board of Directors.? This week AIHC has selected a few stunning cases to review.
Hospital Reporting of Patient Harm Events per CMS and State Requirements
January OIG Work Plan Item
“Hospitals collect information about patient harm events to meet Medicare requirements to measure, analyze, and track adverse patient harm events. Hospitals are also required to report certain types of harm events to meet CMS program and State legal requirements.” According to the January 2025 Work Plan.?
The Office of Inspector General’s prior work has found hospitals reporting few harm events to State reporting systems (OEI-06-09-00092).? The January 2025 Work Plan Item states that the OIG will determine the extent to which hospitals reported harm events as required per CMS program and State requirements by utilizing harm events OIG identified through medical review for the study Adverse Events in Hospitals from October 2018 (OEI-06-18-00400) as the basis for this review. Click Here for the Work Plan Item.
Pfizer Paying Nearly $60 M to Resolve Kickback Allegations
Unlawful kickback practices to encourage providers to prescribe Nurtec
On February 3, 2025 Attorney General Bonta announced a nationwide settlement?against?Pfizer-owned?Biohaven?Pharmaceutical Holding Company.? The settlement addresses allegations of Biohaven submitting false claims to the?Medicaid program and other government healthcare programs related to providing cash and extravagant gifts to healthcare providers in return for prescribing their medication, Nurtec.
Pfizer has agreed to pay, on behalf of Biohaven, a total of nearly $60 million?to resolve federal and state violations, most of which resulted in losses to the federal Medicare program.? Learn more about this case.
Four Pharmacists Sentenced for Roles in $13M Multi-State Fraud Conspiracy
Pharmacist Kindy Ghussin, of Greene County, Ohio, was sentenced on February 6, 2025 to five years and five months in prison; pharmacist Raef Hamaed, of Maricopa County, Arizona, was sentenced on Jan. 8 to 10 years in prison; pharmacist Tarek Fakhuri, of Windsor, Ontario, Canada, was sentenced on Jan. 13 to seven years in prison; and pharmacist?Ali Abdelrazzaq, of Macomb County, Michigan, was sentenced on Jan.?15 to two years in prison.
The defendants collectively caused over $13 million of loss to Medicare, Medicaid, and Blue Cross Blue Shield of Michigan for billing Medicare, Medicaid, and Blue Cross Blue Shield of Michigan for prescription medications that they did not dispense at five pharmacies they owned and operated: Eastside Pharmacy, Harper Drugs, and Wayne Campus Pharmacy in Michigan, and Heartland Pharmacy and Heartland Pharmacy 2 in Ohio.? Learn more about this case.
领英推荐
Pharmaceutical Manufacturer QOL Medical & CEO Pays $350,000
Whistleblower Lawsuit
Florida Attorney General’s Medicaid Fraud Control Unit (MFCU) and 17 other states, including the United States government, received $350,000 from QOL Medical, LLC and Frederick E. Cooper, CEO to resolve allegations of inducing the purchase of Sucraid.? Allegations involve violating the Anti-Kickback Statute, the False Claims Act (FCA).?
From May 1, 2018, to June 30, 2022, QOL and Cooper caused the submission of false claims to Medicaid and other government health care programs by paying remuneration to the clinical laboratory and to beneficiaries.? A team from the National Association of Medicaid Fraud Control Units participated in the negotiations on behalf of the states and included representatives from the offices of the attorneys general for the states of Florida, California, Massachusetts, New Jersey, New York and Ohio. Learn more about this case.
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