Med. Management Grp. of Orlando v State Farm
A State Farm insured patient injured in an auto accident had a MRI ordered by her physician. MMGO referred the patient to Premier Advanced Imaging where the MRI was performed. The bill for the MRI from Premier to MMGO was $350. MMGO turned around and billed State Farm $1400 for the test. State Farm rightfully refused to pay and was sued by MMGO. MMGO stated they were entitled to the money since insurers in Florida are required to pay 80% of medically necessary medical services and they had a deal with Premier where they leased space, equipment for Premier's right to bill. The trial court and the District court of Appeal both stated that this is a fee-splitting scheme to get referrals and is against state law. Referral and billing services are not medically necessary and non-compensable. God love the entrepreneurs of Florida. They gave us the Stark and Kickback bills and now this. I would hope the decision is well publicized and that all insurers follow suit and refuse to pay these intermediates. The intermediates and the MRI companies would not only lose all money they could have obtained legally but also lose all court costs. Top
Statute of Limitations
Little v St. Paul Mercury Ins. Co.
Following a suicide in a hospital psychiatric unit, a relative requested information about the death and received the medical records. He was on every 15 minute suicide watch but this was not done according to the records. The hospital administrator was asked why they were not done and he lied and said he would look into it. He knew that employees had been discharged because of the incident. Four years later the relative received an anonymous tip about the incident. She sued and lost on the summary judgment since, even though the administrator lied, the medical records were enough to put the relative on notice that there was a basis for a suit. Top
Scales v Rapides Regional Med. Ctr.
The patient had a post-op infection and sued the hospital four months after learning that the hospital had suspended the surgeon for a high complication rate. She found out about the suspension because the surgeon sued the hospital over the credentialing in federal court where there is no peer review protection. Using this public information, she sued and lost in the trial court due to the one year statute of limitations since the surgery. The appeals court reversed the trial court and said that this is different than medical malpractice. She timely filed after learning about the surgeon's practices and the hospital's action. This does not mean she will win since I am not sure that the complication that she occurred was late enough for the medical staff to know that there was a pattern of complications. This is another reason to watch for the difference between federal and state law in peer review protections. Top
The law suit against Purdue Pharma, the maker of the drug, OxyContin, will not be certified for a class action sayeth the judge. The attorney tried to get the class action after suing the physician who prescribed the medicine and the maker for overprescribing the drug. The four patients claim they became addicts after taking the drug. The doctor is in prison for criminal overprescribing. The case will go forward as four individuals against the incarcerated physician and the company. Purdue Pharma is taking out ads in multiple newspapers to stress its attempting to contain the abuse of a great drug. Purdue Pharma has already been found not guilty in another case involving the drug and the lack of warnings. The incarcerated physician I'm sure has alot of assets. Good luck to the attorney making any money.
In Milton, Florida Dr. James Graves was found guilty of four counts of manslaughter on four ODs, one count of racketeering and five counts of unlawful delivery of a controlled substance. He may be sentenced to 30 years. Several pharmacists testified they had stopped filling "Graves Cocktails", Lortab, Xanax, Soma, and OxyContin. He had about 1000 pain patients and made about $500,000 per year. Top
Hason v Medical Board of Calif.
Hason sued the Board and the individual members and the investigators under the American Disability Act, ADA. In 1998,Dr. Hason applied for and was denied a license to practice medicine in the state. The rationale for the refusal was mental illness. He originally filed the suit pro se. The district court ruled against him for three reasons (1) it was against the 11th Amendment, (2) no valid ADA state claim and (3) claims against the individuals should be dismissed due to failure to prosecute. The 9th Circuit overruled the District Court and relooked at the entire case de novo. Under the 11th Amendment, the 9th Circ stated that even though the law bars the filing of a suit by a private person against a state in federal court, it can be done where Congress in the ADA Title II has stated that the state can be sued in federal court. The 11th Amendment also does not bar a suit against the individuals in their official capacity to enjoin their conduct of breaking federal law. The second aspect regarding a valid ADA state claim was also overturned since the granting of a license is considered as a service of the state and covered under Title II. Also the matter of whether the doctor is a qualified individual under the ADA is a matter of fact and for a jury to decide, not a matter for summary judgment. The doctor also stated that by the time the Board acted he had received treatment and was no longer disabled and now able to practice medicine. In the failure to prosecute decision, the 9th agreed and upheld the inability to go after the individuals individually due to failure to prosecute. The case was then remanded to District Court for trial. The ball is now in the MBCs court if they wish to go to the expense of trial and the great possibility of losing or allow Hason to be licensed.
Ocampo v Dept. of Health
In an interesting bit the Florida Department of Health attempted to take away the license of Dr. Ocampo. His crime was being excluded from the Medicare program. Dr. Ocampo agued that the exclusion from the program is not a reason to revoke or take action on his license. The exclusion means he cannot see Medicare patients but this was not a action that would affect his license being acted against by another agency.
Conn. v Anthem Blue Cross Blue Shield
A San Francisco man has pled guilty of hacking into the CHW computer system. He sent e-mails to all the employees of CHW defaming several employees. He can be sentenced to one year in prison and a $100,000 fine. He will probably be sued civilly as well but I doubt whether any money would be forthcoming from that. Top
US v Abba Eye Care
In the usual settlement, Abba Eye Care and Dr. Meyer agreed to pay $162,296 for unbundling of charges in their Medicare and Medicaid billings. They will also be placed under a Corporate Integrity Agreement. They are to hire an independent entity to monitor their billing practices and submit reports to the OIG. The company charged separately for sensorimotor tests along with intermediate and/or comprehensive exams in which the sensorimotor tests should have been included.
US v Randall
Dr. Russell Randall agreed to pay the Feds $33,000 for overbilling Medicare. His settlement denied any intention of fraud or other illegal action. What he did was change the location on the billing form from a location where payment would not be made to a location where payment would be made. It could not have been much since the fine is so small. He was also not excluded from the Medicare program.
US v Rotech
Rotech, a medical supplier, has agreed to pay $17 million for overbilling the government.. They also had to sign a Corporate Integrity Agreement, a document that requires someone to look over their shoulder on their billing issues. The claim against them is the presentation of false or forged claims for medically unnecessary drugs and equipment.
People v Sharpe
Mark J. Sharpe, a psychologist with multiple centers, was convicted by a jury of Medicaid fraud. He had psychology service centers in six locations and had other psychologists do the counseling. The testimony showed that 1300 patients were billed for services not provided or with higher than provided codes. He stated he was duped by a the poor work of one billing clerk. He now goes to the pokey for four years plus six on probation and a $50,000 fine. Top
Multiple Plaintiff v Multiple Defendants
In the large class action suit against multiple HMOs for fraud and RICO complaints, the complaints against Aetna, Cigna and United Healthcare can proceed. Dropped were Prudential Aetna in California and Virginia and Health Net in Florida. the rationale for dropping these entities were the state laws regarding insurance fraud. Another claim dropped by the judge was the medical necessity aspect of denial of claims for financial reasons. This avenue was still open for former members of the plan but current members needed to go through administrative channels. The next phase is whether or not class action will be certified. A recent 11th Circuit case (Florida's Circuit) ruled in another case each person must prove that telephone calls to them are fraudulent. This may screw up the class action. Top
The US Supreme Court ruled in Wisconsin v Blumer that states may choose an income first method of determining when a party is eligible for Medicaid. This is what has been going on but the 6-3 ruling that overturned a Court of Appeal decision makes sure the states don't have to only use the resource-based method. Top
Wrong Site Surgery
Why does this happen so often in Florida? In another recent case, a Florida neurosurgeon operated on the wrong side of the patient's head for a brain bleed. He realized his mistake prior to reaching brain tissue, stopped, closed and then continued on the correct side. If the surgeon and operating room personnel are on their toes and have a good system in place that is being followed there is no excuse for this error.
Altieri v CVS
The children of a woman who died from being given tincture of opium instead of paregoric have filed suit. This case was reported here earlier in the month. Top
A Nebraska woman attempted to kill her husband with an intravenous overdose of insulin. The husband was on IVs recuperating from pancreatic surgery at St. Mary's Hospital, part of Mayo Clinic. She liked Minnesota and did not want to go home. She now may be there for longer than she wanted. The husband is back home in Nebraska.
The Kansas City, Missouri pharmacist accused of diluting chemotherapy drugs has accepted a plea bargain. He has yet to be sentenced but it will be a shorter time than the 196 years he faced by going to trial.
A Oakland chiropractor clinic owner has pled guilty to tax evasion and has been sentenced to a year in prison. She was also in violation of state law since she was not a chiropractor and could not own those clinics. California has a law against non-professionals owning professional corporations. Top
DISCLAIMER: Although this article is updated periodically, it reflects the author's point of view at the time of publication. Nothing in this article constitutes legal advice. Readers should consult with their own legal counsel before acting on any of the information presented.