Nolan Auerbach & White are experienced Hospital Fraud Lawyers helping courageous whistleblowers.
The submission of false or fraudulent pharmacy billing units on claims for outpatient services is an area of growing concern for health care fraud.
CMS’s Medicare Claims Processing Manual, Pub. No. 100-04 (the Manual), chapter 4, section 20.4, states: “The definition of service units … is the number of times the service or procedure being reported was performed.” The Manual, chapter 17, section 90.2.A, states: “It is … of great importance that hospitals billing for [drugs] make certain that the reported units of service of the reported HCPCS code are consistent with the quantity of a drug … that was used in the care of the patient.” If the provider is billing for a drug, according to chapter 17, section 70, of the Manual, “[w]here HCPCS is required, units are entered in multiples of the units shown in the HCPCS narrative description.”
For the line items for drugs, dishonest hospitals have regularly billed Medicare and Medicaid for the incorrect number of units of service. For instance, rather than billing from 60 service units, a hospital falsely bills 120 service units. While hospitals often blame incorrect descriptions in charge masters and electronic health record systems, it is a violation of the False Claims Act to maintain such systems with reckless disregard.
Kathleen Hawkins, RN MSN, had been employed by Defendant, Catholic Healthcare West (CHW) for approximately 6 years when she decided she had had enough of trying to change the hospital system from within.
CHW, a California not-for-profit corporation that operated hospitals in California, Arizona, and Nevada, was at the time the eighth largest hospital system in the nation and the largest not-for-profit hospital provider in California.
Joe Strom contacted us in 2005. We were very grateful that he did. We immediately formed an all-star legal team and a process to stop a very harmful pharmaceutical marketing strategy. It was this process we set into motion that ultimately returned hundreds of millions of dollars to the U.S. Treasury, and a portion of that, very well-deserved, into Joe’s bank account.
Joe told us a very troubling story about the off-label promotion of a pharmaceutical drug for patients who already suffered from chronic heart failure.
Bruce Moilan was a seasoned hospital systems expert by the time he contacted our Firm. At the time he decided to file his qui tam lawsuit, he was employed by South Texas Health System as a System Director for Materials Management. In this position, he oversaw $24 million in annual purchases of supplies and equipment and helped determine budget, reduction and cost analysis throughout the contract bidding and negotiations process. His job was to insure proper implementation for purchasing, receiving and management of inventory, for McAllen Hospitals, L.P.