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DOJ

Escobar’s Materiality Standard Shields Organizations from the Risk in Risk Adjustment Payments

Finance Director for UnitedHealth Group brought qui tam suit against UnitedHealth Group, Inc. alleging that the organization upcoded risk adjustment data resulting in increased payments (more than $1.14 billion) to UnitedHealth Group. The Department of Justice (DOJ) intervened in the case, yet UnitedHealth Group was successful in getting the primary False Claims Act Claims dismissed by arguing that the Centers for Medicare & Medicaid Services (CMS) would not have refused to make the adjustment payments had they known of the errors in the risk adjustment. The Escobar materiality standard helps clarify threshold level of risk to Managed Care Providers in attesting to their risk adjustment payments; the falsities must have had an impact on the respective payment.

My Summer with the Office of Inspector General for the U.S. Department of Health and Human Services

This summer I had the opportunity to intern with the Office of Inspector General for the U.S. Department of Health and Human Services (OIG) in Washington, DC. I thoroughly enjoyed my time with OIG, and I learned a great deal about health care fraud, waste, and abuse. In spending my summer with OIG, I had a glimpse into the powerful regulatory bodies that protect the health care market from abuse. As I move forward with my career in regulatory work, I will take with me the invaluable experiences and skills from my internship.

DOJ Joins Whistleblower Suit Against UnitedHealth Group

The United States Department of Justice (“DOJ”) recently intervened in a qui tam action against UnitedHealth Group (“United”) and its subsidiary, UnitedHealthcare Medicare & Retirement, the nation’s largest provider of Medicare Advantage (“MA”) Plans. The suit alleges that United engaged in an “up-coding” scheme to receive higher payments than they should have under MA’s risk adjustment program. Assuming these allegations of United’s false claims are true, then United billed and received hundreds of millions of dollars in improper payments from Medicare.

New Era of Healthcare Fraud Investigations Focuses On Individual Accountability

Fannie Fang Executive Editor Loyola University Chicago School of Law, JD 2017   Traditionally, only healthcare corporations were held responsible for healthcare fraud. During an investigation, these corporations were only required to provide contextual information about the underlying factual situation in a fraud investigation. Additionally, healthcare corporations would typically enter into settlement agreements with the …
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Two Former Nursing Home Executives and Two Accomplices Steal Over $16 Million Through Kickbacks and Overcharges

Alexander Thompson Associate Editor Loyola University Chicago School of Law, J.D. 2018   Two former executives of American Senior Communities and two accomplices have been indicted on numerous charges by the Department of Justice. The two former executives: CEO James Burkhart and Daniel Benson were arraigned on charges of health care fraud and conspiracy to …
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Another Suit against Vanguard Healthcare

Kaitlin Lavin Executive Editor Loyola University Chicago School of Law, JD 2017   In 2011, Vanguard Healthcare, LLC (“Vanguard”) settled a whistleblower suit for Medicare and Medicaid fraud and entered into a Corporate Integrity Agreement (CIA). Now the federal government is suing Vanguard for submitting fraudulent claims for services that were “either non-existent or grossly …
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Lessons Still to be Learned from Settlements of Implantable Cardiac Device Cases

Gail Jankowski Executive Editor Loyola University Chicago School of Law, JD 2016   Although the DOJ reached 70 settlements involving 457 hospitals in 43 states for more than $250 million related to cardiac devices that were implanted in Medicare patients which violated coverage requirements, they were not done yet. Another batch of 51 hospitals settled …
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