DECEMBER 26, 2023. In today’s Fraud Fighters HHS-OIG Fall Summary Annual Report Wrap-up , we are covering two whistleblower cases discussed in this report as part of civil enforcement activities related to Medicaid and Medicare. The previous installment can be read here.
Managed Care Fraud Whistleblower
Martin’s Point Health Care of Maine agreed to pay $22.5 million to settle allegations of violating the False Claims Act related to its Medicare Advantage (MA) plans. As an MA plan operator, Martin’s Point receives risk-adjusted payments from Medicare based on enrollee health conditions.
From 2016 to 2019, Martin’s Point allegedly conducted chart reviews to identify additional diagnosis codes not originally submitted to Medicare, even when unsupported by medical records. By submitting these unsubstantiated codes, Martin’s Point received inflated payments, according to the government’s allegations. A former manager in the Medicare Advantage Organization’s Risk Adjustment Operations group filed a qui tam lawsuit against the company, calling out their upcoding scheme.
Medical Device Fraud Whistleblower
Michigan vascular surgeon Vasso Godiali was sentenced to 80 months in prison for his role in leading a scheme to defraud public health programs out of $19.5 million by billing for medical procedures that were never performed. From around 2009, Godiali submitted fraudulent claims to Medicare, Medicaid, and Blue Cross Blue Shield of Michigan, billing for multiple vascular stents in the same blood vessel and nonexistent thrombectomies. False medical records were created to justify the fraudulent billing and bill for services that were not rendered.
The allegations in a related False Claims Action state that Godiali submitted false claims to government-funded healthcare programs through unbundled services to separately bill for them and thus increase his reimbursements. A corporate relator, Innovative Solution Consulting, LLC, filed a qui tam lawsuit against the healthcare provider, bringing this multi-million dollar medical device fraud scheme to light. As part of a plea agreement, Godiali must repay $19.5 million in restitution and faces additional civil penalties of up to $43 million.
To continue its watchdog mission, HHS-OIG relies, in part, on whistleblowers exposing fraudulent actions against these Medicare, Medicaid, and other government-funded healthcare programs.
If you would like to report healthcare fraud, including Medicare or Medicaid fraud, you can contact attorneys at Tycko & Zavareei LLP. Eva Gunasekera and Renée Brooker are former officials of the United States Department of Justice and prosecuted whistleblower cases under the False Claims Act. Renée served as Assistant Director at the United States Department of Justice, the office that supervises False Claims Act cases in all 94 United States District Courts. Eva was the Senior Counsel for Health Care Fraud. Eva and Renée now represent whistleblowers. For a free consultation, you can contact Renée at [email protected] (tel.: 202-417-3664) or contact Eva Gunasekera at [email protected]. You can also go to Tycko & Zavareei LLP’s website for whistleblowers to learn more at www.fraudfighters.net.