UnitedHealthcare Accuses Dallas Labs Of $100M Fraud Scheme

Discussion in 'Laboratory/Diagnostic Sales General Discussion' started by anonymous, Jan 27, 2017 at 7:23 PM.

Tags: Add Tags
  1. anonymous

    anonymous Guest

    https://www.law360.com/health/articles/885558/unitedhealthcare-accuses-dallas-labs-of-100m-fraud-scheme

    Law360, New York (January 27, 2017, 2:33 PM EST) -- UnitedHealthcare Insurance Co. on Thursday lobbed multiple federal claims against Dallas-based Next Health LLC and several subsidiaries that perform drug and genetic laboratory testing, saying that the companies defrauded the insurer of more than $100 million over several years through improper billing connected to a physician and referral source kickback scheme.
    In an 81-page complaint, UnitedHealthcare detailed an array of various alleged kickback schemes involving unnecessary and expensive drug testing coordinated through Next Health, its subsidiaries and individual agents that cost the insurer and several self-funded insurance plans millions of dollars in charges for unlawful commercial insurance claims.

    According to the complaint, the defendants inappropriately utilized standing test protocols regardless of patients’ medical histories or clinical conditions, performed and billed for testing services that were not ordered by physicians, improperly billed for services that they did not perform and routinely ignored patients’ payment responsibilities to avoid drawing attention to the scheme.

    “Next Health used kickbacks, unnecessary testing protocols and unlawful business practices to bilk Texas charities, retirees and taxpayers out of millions of dollars,” the complaint states. “United brings this action to stop Next Health’s scheme.”

    A representatie for Next Health did not immediately respond to a request for comment on Friday.

    UnitedHealthcare said that the alleged schemes were carried out between 2011 and mid-2016, when the insurer identified illegal testing activity after a routine claims review and launched an investigation into Next Health and its subsidiaries United Toxicology LLC, Medicus Laboratories LLC, US Toxicology LLC and American Laboratories Group LLC. The investigation revealed that Next Health funneled kickbacks or bribes to providers in multiple geographic areas for drug and pharmaco-genetic test orders, the insurer said.

    One of the alleged schemes, facilitated by individual defendants Erik Bugen and Kirk Zajac, involved recruiting patients with commercial insurance to participate in a “wellness study,” which required them to report to a clinic to provide urine or saliva specimens in exchange for $50 gift cards. Those specimens were then sent to Next Health for testing, ultimately leading UnitedHealthcare to pay out more than $11 million in insurance claims to the subsidiaries, the suit said.

    According to the complaint, one of the locations used to collect patient samples did not have a restroom, and when the building’s public restroom was full, patients were told to use a restroom in a nearby Whataburger restaurant.

    Bugen and Zajac allegedly earned 20 percent kickbacks through this scheme, and only stopped around May 2016 when a CBS News investigation uncovered the operation they were running.

    UnitedHealthcare said that if any of the alleged schemes sound familiar, it is because the U.S. Department of Justice recently indicted several executives, surgeons, physicians and others in connection with a similar illegal kickback conspiracy at Forrest Park Medical Center, including Semyon Narosov and Andrew Jonathan Hillman, who held and may still hold ownership or management positions with Next Health or one or more of its subsidiaries.

    With its suit, the insurer seeks to put a stop to the alleged illegal operations, be free from further paying out any claims to Next Health, recover damages in the amount of fraudulent payments it made to the defendants and money spent on investigating the alleged practices and also receive punitive damage payments.

    UnitedHealthcare is represented by Stephen W. Mooney of Weinberg Wheeler Hudgins Gunn & Dial LLC.

    Counsel information for the defendants was not immediately available on Friday.

    The case is United Healthcare Services Inc. et al. v. Next Health LLC et al., case number 3:17-cv-00243, in the U.S. District Court for the Northern District of Texas.

    --Editing by Stephen Berg.
     

  2. anonymous

    anonymous Guest

    Is southwest labs involved in this? Sounds very similar to there MSO model.
     
  3. anonymous

    anonymous Guest

    read the lawsuit...this is not merely an MSO model. They were alleged to have given gift cards to patients. Alleged to have billed for tests never signed off by patients. Alleged to have told patients they have absolutely no responsibility to pay (fee forgiveness). There is a little more as well. All allegations, of course, so have to wait and see what comes out.
     
  4. anonymous

    anonymous Guest

    Someone needs to investigate Salubrity Group of Texas. They are the same type of company and have been doing the same thing. Several of my family members fell victim to this as well. Their insurance companies were billed unusually high amounts and they still got bills.
     
  5. anonymous

    anonymous Guest

    Almost three years ago I uncovered fraud and forgery perpetrated by people working for Semyon Narosov and Andrew Jonathan Hillman. In fact, the forgery was with prescription medication and the DEA got involved. Also these two are involved in the kickbacks with Forest Park Medical Center. No wonder our healthcare costs continue to increase with people like this doing things like this. Oh, yeah, the forgery was regarding refills for an $11,000 jar of "pain cream" and a $2,000 jar of "scar reduction cream." First of all I didn't need either, never used either and my doctor was completely unaware of the cost of these "compounded" creams and certainly did not write the prescription for a refill nor at any time granted or authorized a refill. Further, the sales rep for these two went to my doctor's office and rifled through their files to find my name and number--thus violating my HIPAA privacy--she had no need for access to my medical information. This bunch gathers renegades who will evidently do anything for a buck. Maybe a very long prison sentence is in order for them all....as well as surrender of the $7 million home that Narosov owns in Preston Hollow-Dallas.
     
  6. anonymous

    anonymous Guest

    ARe you kidding me. READ the article. The people at Next Health are crooks and always have been crooks only this time they got caught once too many times and will be serving jail time for a change. They were working with someone who had been convicted of fraud and forgery. How stupid can you be? This isn't a case of one distributor going rouge and nothing else wrong. Next Health has shown it was willing to do anything to get business legit or not before and they have been caught with their pants down once again. I would estimate that this lab goes under within 6 months if they last that long. Do you think United will be the only insurance carrier wanting to get a ton of money back? Yo can count of loads of other insurance carriers suing them too and demanding one audit after another. If United can figure out that Next Health was crooked don't you think the Feds will want to take down these guys over the coruption regarding the federally insured patients? This is just the begining of a legal fight with lots and lots of companies and the feds. Employees and reps will be leaving in droves. If you were a physician wouldn't you want to drop working with this bunch of crooks today? Anyone and EVERYONE that is using this lag is going to be investigated and espically the physicians demanding to try and see if they were getting paid off in one way or another. It won't matter if you were one of the few honest physicians or reps because your name and repuitation will get dragged into the slime and mud.
     
  7. anonymous

    anonymous Guest

     
  8. anonymous

    anonymous Guest

    In December, 2016, Semyon Narosov and Andrew Jonathan Hillman we indicted by the US Attorney for kickbacks related to the now closed Forest Park Medical Center. Further, Narosov owner a compounding pharmacy that committed fraud and forgery about 3 years ago--i know because i was the patient involved and caught it--reported it and the DEA got involved. I even met with the "chief compliance officer" of the (then) holding company US Health (now defunct). These yahoos continue to try new names for the same old scams. A few weeks ago at the request of the FBI I met with three special agents of the FBI in the local FBI office here in Dallas to review with them what I know first hand about this bunch. Oh, by the way, the chief compliance officer for US Health is on the Next Health leadership team as chief compliance officer.....not sure what he is "compliant" with, but it sure does not appear to be integrity.
     
  9. anonymous

    anonymous Guest

    Who is the chief compliance officer you are referring to? Website seems down.
     
  10. anonymous

    anonymous Guest

    any updates on this?
     
  11. anonymous

    anonymous Guest

    I heard that Hillman and Symon filed a motion to dismiss the charges due to statue of limitations???
     
  12. anonymous

    anonymous Guest

    Regarding the United Healthcare lawsuit or their personal indictments?
     
  13. anonymous

    anonymous Guest

    The case is public record. Both the civil and criminal. Motions practice is standard in the litigation realm nothing world shattering. I did hear they got a nice visit from CLIA.
     
  14. anonymous

    anonymous Guest

    Why would these guys do this in a state that has criminal charges for commercial kickbacks??! - There are lots of states that only have civil penalties for commercial kickbacks!
     
  15. What is ACCUSATION?
    The formal charge that is made in court where a person is guilty of a offence that is punishable.

    What is FRAUD?
    Fraud consists of some deceitful practice or willful device, resorted to withintent to deprive another of his right, or in some manner to do him an injury. As distinguishedfrom negligence, it is always positive, intentional. Maher v. Hibernia Ins. Co.,67 N. Y. 292; Alexander v. Church, 53 Conn. 501, 4 Atl. 103; Studer v. Bleistein. 115 N.Y. 31G, 22 X. E. 243, 7 L. R. A. 702; Moore v. Crawford, 130 U. S. 122, 9 Sup. Ct. 447,32 L. Ed. 878; Fechheimer v. Baum (C. C.) 37 Fed. 167; U. S. v. Beach (D. C.) 71 Fed.160; Gardner v. Ileartt, 3 Denio (N. Y.) 232; Monroe Mercantile Co. v. Arnold, 108 Ga. 449, 34 S. E. 176.Fraud, as applied to contracts, is the cause of an error bearing on a material part ofthe contract, created or continued by artifice, with design to obtain some unjustadvantage to the one party, or to cause an inconvenience or loss to the other. CivilCode La. art. 1S47.Fraud, In the sense of a court of equity, properly Includes all acts, omissions, andconcealments which involve a breach of legal or equitable duty, trust, or confidencejustly reposed, and are injurious to another, or by which an undue and unconscientiousadvantage is taken of another. 1 Story, Eq. Jur.

    What is CRIMINAL INTENT?
    The intent to commit a crime: malice, as evidenced by a criminal act; an intent to deprive or defraud the true owner of his property. People v. Moore. 3 N. Y. Cr. R. 458. (source: Black's Law Dictionary)

    Criminal Intent: Overview

    Criminal intent is a necessary component of a "conventional" crime and involves a conscious decision on the part of one party to injure or deprive another. It is one of three categories of "mens rea," the basis for the establishment of guilt in a criminal case. There are multiple shades of criminal intent that may be applied in situations ranging from outright premeditation to spontaneous action.

    It is possible to establish criminal intent even when a crime is not premeditated. Individuals who commit a crime spontaneously may still understand that their actions will cause harm to another party and contravene existing criminal law. In other words, an individual that takes or withholds action with the knowledge that such behavior will lead to the commission of a crime can be said to possess criminal intent.

    Criminal Intent: What You Should Know

    While criminal intent is a necessary component of mens rea in virtually every modern legal system, its particulars may vary between jurisdictions. There often exists a distinction between "basic intent" and "specific intent."

    Since it requires a lighter burden of proof, the former is used more often to establish criminal intent. For instance, an individual who strikes a pedestrian crossing the street in a marked crosswalk can be said to have exhibited "basic intent" whether or not they intended to cause the pedestrian harm. There are two reasons for this. First, the driver may have ignored state and local law requiring vehicles to yield to pedestrians in crosswalks. Absent such laws, the driver either failed to pay close attention to the road ahead or assumed that the pedestrian would be able to avoid their oncoming vehicle. In either case, the driver abdicated their legal responsibility to take reasonable precautions to ensure the safety of others on the road.

    "Specific intent" is invoked less frequently and often applies to cases in which the accused intends to commit a crime but has not yet done so. It may be used to justify preventive detentions associated with terrorism, treason or sabotage. For instance, an individual who has communicated his intent to assassinate an official may be judged to exhibit specific intent on the basis of his or her pronouncements.

    Criminal intent may be further categorized as either "direct" or "oblique." Defined as a desire to commit a specific act in the expectation that it will result in a specific outcome, the former may be used to prove premeditation. For instance, an individual who purchases a firearm and uses it in a mugging exhibits direct intent to threaten another with deadly force.

    By contrast, "oblique" intent may be used to establish guilt in cases that involve unintended consequences. An individual who undertakes a specific action with the knowledge that it may cause certain consequences can be said to have oblique intent. For instance, an individual who injures someones by firing a gun into the air near a crowd may be held responsible for that injury despite a lack of direct intent to cause harm.

    What is DUE PROCESS OF LAW?
    Law in its regular course of administration through courts of justice. 3 Story, Const.264, 661. “Due process of law in each particular case means such an exercise of the powers of the government as the settled maxims of law permit and sanction, and under such safeguards for the protection of individual rights as those maxims prescribe for the class of cases to which the one in question belongs.” Cooley, Const. Lira. 441. Whateve rdifficulty may be experienced in giving to those terms a definition which will embrace every permissible exertion of power affecting private rights, and exclude such as is forbidden, there can be no doubt of their meaning when applied to judicial proceedings.They then mean a course of legal proceedings according to those rules and principles which have been established in our systems of jurisprudence for the enforcement and protection of private rights. To give such proceedings any validity, there must be a tribunal competent by its constitution

    What is INDICTMENT?
    A written accusation of one or more persons of a crime or misdemeanor, presented to, and preferred upon oath or affirmation, by a grand jury legally convoked.

    What is TRIAL?
    The examination before a competent tribunal, according to the law of the land, of the facts or law put in issue in a cause, for the purpose of determining such issue. A trial is the judicial examination of the Issues between the parties, whether they be issues of law or of fact. Code N. Y.
     
  16. These guys are great people ! Family people only the people here sound like they are jealous people or screwed the company or stole. These guys have a ton of staff thats worked over 10 years this thread sounds like a bunch of losers! Thats whats wrong with the United States of America so many people are so jealous and try to take others down when they fail! So sad where our country has gone to! Sorry you guys need a job work or energy! You guys are losers! And your hurting families and people why dont you go work and try not to take others down where you are in life! So sad!
     
  17. United Health sinks after being sued by the US government (UNH)

    United Health is down 3.76% at $157.50 a share on Friday morning after news that the US Justice Department joined a 2011 lawsuit by a former United Health executive against the health insurer.

    The lawsuit claims that United Health overcharged Medicare by hundreds of millions of dollars by claiming the program's participants were sicker than they actually were, according to the law firm Constantine Cannon LLP.

    Constantine Cannon posted the lawsuit online when it was unsealed on Thursday.

    See Also: Unilever rejected Kraft's takeover offer and the stock is soaring

    [​IMG]Markets Insider








     
  18. anonymous

    anonymous Guest

    UnitedHealth sued by U.S. government over Medicare charges

    The U.S. Justice Department has joined a whistleblower lawsuit against UnitedHealth Group Inc that claims the country's largest health insurer and its units and affiliates overcharged Medicare hundreds of millions of dollars, a law firm representing the whistleblower said on Thursday.

    "We reject these more than five-year-old claims and will contest them vigorously," UnitedHealth spokesman Matthew Burns said in a statement.

    The lawsuit, filed in 2011 and unsealed on Thursday, alleges UnitedHealth Group overcharged Medicare by claiming the federal health insurance program's members nationwide were sicker than they were, according to the law firm Constantine Cannon LLP.

    The Justice Department has also joined in allegations against WellMed Medical Management Inc, a Texas-based healthcare company UnitedHealth bought in 2011.

    The lawsuit by whistleblower Benjamin Poehling, a former UnitedHealth executive, has been kept under seal in federal court in Los Angeles while the Justice Department investigated the claims for the past five years. Constantine Cannon posted the lawsuit online when it was unsealed on Thursday. (bit.ly/2lQTOh8)

    No total damages were specified in the lawsuit.



    (Corrects last name to "Poehling" from "Phoeling" in paragraph 5)



    (Reporting by Akankshita Mukhopadhyay and Laharee Chatterjee in Bengaluru; Editing by Lisa Shumaker)
     
  19. Feds sue UnitedHealth alleging at least $1 billion in false claims
    The government's complaint comes in a whistleblower case brought by a former employee in Minnesota.
    By Christopher Snowbeck Star Tribune

    MAY 17, 2017 — 7:35AM
    [​IMG]
    GLEN STUBBE - STAR TRIBUNE FILE
    UnitedHealth Group Headquarters in Minnetonka.
    The federal government sued UnitedHealth Group on Tuesday alleging the Minnetonka-based health care company wrongly received from Medicare at least $1 billion in “risk adjustment” payments based on inaccurate data submissions.

    The government took issue with what it called “one-sided” chart reviews that focused on maximizing taxpayer dollars to the nation’s largest health insurer, but didn’t correct errors that allegedly inflated the company’s revenue, according to the lawsuit filed in the U.S. District Court for the Central District of California.

    Risk adjustment payments are made to private insurers that operate “Medicare Advantage” plans, which are an increasingly popular way for beneficiaries to obtain their government health insurance benefits. Tuesday marked the second time in a few weeks that the Justice Department filed a complaint against UnitedHealth over allegations of inflated risk adjustment payments.

    “The primary goal of publicly funded health care programs like Medicare is to provide high-quality medical services to those in need — not to line the pockets of participants willing to abuse the system,” said acting U.S. Attorney Sandra R. Brown in a news release.

    In an earlier statement, United Health spokesman Matthew Burns said, “we are confident our company and our employees complied with the government’s Medicare Advantage program rules, and we have been transparent with [Centers for Medicare and Medicaid Services] about our approach under its unclear policies. We reject these claims and will contest them vigorously.”

    UnitedHealthcare, which is the company’s health insurance division, is the nation’s largest provider of Medicare Advantage plans.

    The federal government’s civil fraud action comes in a whistleblower case first brought by a former UnitedHealth Group employee named Benjamin Poehling who worked for the company in the Twin Cities. The government said it would join the case in February, at which point Poehling’s initial lawsuit was made public.

    In March, the federal government said it would join a second whistleblower case against UnitedHealth that raised similar allegations about risk adjustment payments in Medicare, which is the massive federal health insurance program covering Americans age 65 and older.

    Earlier this year, the federal government disclosed it had ongoing investigations about risk adjustment practices at four other carriers including Aetna and a division of Cigna. Rules for how payments should be risk adjusted for patient illnesses have been controversial in the past, with UnitedHealthcare suing the federal government in January 2016 over a change in guidance on how to assess the health status of enrollees.

    Last month, a federal judge ruled the UnitedHealthcare lawsuit against the government could proceed, despite efforts to have the case tossed out on procedural grounds.

    In Medicare Advantage plans, the government pays health insurers a per-member per-month payment for enrollees. The government says the fees can be increased when health plans submit information about an enrollee’s health that justifies a higher “risk score” for the patient.

    The adjustments are meant to make sure Medicare Advantage plans are paid more for enrollees expected to incur higher health care costs.

    To make sure Medicare doesn’t make erroneous payments to health plans, the government says information about diagnoses must be supported by the patient’s medical records.

    The federal lawsuit filed Tuesday highlighted UnitedHealth’s program to review charts, calling it a “one-sided revenue-generating program.”

    The insurer collected “millions of medical records” and employed chart reviewers “in order to mine for diagnoses that the providers themselves did not report to United for their patients,” the lawsuit states. “United used the results of the chart reviews to only increase government payments ... while in bad faith systematically ignoring other information from the chart reviews which would have led to decreased payments.”

    It goes on to say: “Since at least 2005, United has known that a significant percentage of diagnoses reported by providers to it … are invalid because the beneficiaries’ medical records do not substantiate that the beneficiaries had the medical conditions identified by the diagnosis codes reported by the providers.”

    The claims asserted against UnitedHealth are allegations only, the federal government said in a statement, adding that there has been no determination of liability.

    Whistleblower cases alleging false claims are brought by “relators” such as Poehling, the former UnitedHealth employee, on behalf of the federal government. They are designed to recover funds for the government, with relators receiving a portion of the recoveries.

    EMAIL

    chris.snowbeck@startribune.com ChrisSnowbeck
     
  20. FOR IMMEDIATE RELEASE
    Monday, August 15, 2016
    Justice Department Files Lawsuit Against United Airlines for Violating Employment Rights of U.S. Air Force Reservist
    The Justice Department filed a complaint today alleging that United Airlines Inc. violated the employment rights of U.S. Air Force Reservist Lieutenant Colonel Daniel Fandrei under the Uniformed Services Employment and Reemployment Rights Act (USERRA).

    According to the complaint, United violated USERRA by denying Fandrei employment benefits during his military leave that it grants to other employees for similar types of leave. Specifically, the complaint alleges that United failed to credit Fandrei with sick leave for his active duty deployment in 2012 and 2013. During that time, Fandrei was mobilized as a KC-10 pilot in Southwest Asia. Fandrei served his country as part of the Air Force from 1990 until 2016.

    “Individuals who serve bravely in our armed forces should be treated fairly by their employers while they are actively deployed,” said Principal Deputy Associate Attorney General Bill Baer. “Through the department’s newly-created Servicemembers and Veterans Initiative, we will continue to build on our strong ties with federal partners and continue using every tool at our disposal to protect the rights of the men and women who serve in our armed forces.”

    “USERRA ensures that servicemembers like Lt. Col. Fandrei who answer our nation’s call to duty don’t return to civilian life and find their employment benefits denied and their civil rights violated,” said Principal Deputy Assistant Attorney General Vanita Gupta, head of the Justice Department’s Civil Rights Division. “The Department of Justice will continue to vigorously enforce the law to safeguard the rights of those who defend our country and protect our freedom.”

    “Lt. Col. Fandrei has made many sacrifices to serve our nation honorably, including spending months away from his job and family,” said U.S. Attorney Zachary T. Fardon of the Northern District of Illinois. “When our servicemembers are deployed in the service of our country, they are entitled to retain their civilian employment and benefits, and to the protections of federal law that prevent them from being subject to discrimination based upon their military obligations.”

    The lawsuit filed by the United States seeks damages equal to the amount of Fandrei’s lost benefits caused by United’s failure to comply with USERRA. It also seeks an order requiring United to comply with all provisions of USERRA.

    USERRA protects the rights of uniformed servicemembers to retain their civilian employment prior to, during and following absences due to military service obligations, and provides that servicemembers shall not be discriminated against because of their military obligations. Under USERRA, the department has authority to represent a servicemember if the department is satisfied that the servicemember is entitled to the rights or benefits being sought.

    Fandrei initially filed a complaint with the Department of Labor’s Veterans’ Employment and Training Service, which investigated this matter and, after resolution failed, referred it to the Justice Department’s Civil Rights Division. This lawsuit followed as a collaborative initiative between the Civil Rights Division and the U.S. Attorney’s Office of the Northern District of Illinois. The Justice Department has prioritized the enforcement of servicemembers’ rights under USERRA. Additional information about USERRA can be found on the department’s websites at www.usdoj.gov/crt/emp and www.servicemembers.gov, as well as on the Labor Department’s website at www.dol.gov/vets/programs/userra/main.htm.

    United Airlines Complaint

    Topic(s):
    Civil Rights
    Servicemembers Initiative
    Component(s):
    Civil Rights Division
    Civil Rights - Employment Litigation
    USAO - Illinois, Northern
    Press Release Number:
    16-949