Articles Tagged with Medical

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medicare fraud
In the world of False Claims Act qui tam cases, the concept of medical necessity is a very big issue.

Medicare Fraud

This is because Medicare requires, as a condition of coverage, that services delivered to a patient be “reasonable and necessary for the diagnosis or treatment of illness or injury.”  See 42 U.S.C. § 1395y(A)(1)(a).  Healthcare providers who wish to participate in the Medicare program must ensure that their services are provided “economically and only when, and to the extent, medically necessary.”  See 42 U.S.C. § 1320c-5(A).  In other words, Medicare only pays for services that are “medically necessary.”

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Each year, Medicare beneficiaries can make changes to their Medicare health plans and prescription drug coverage between October 15 and December 7, during the Medicare Open Enrollment Period.  Unfortunately for consumers, this period is also open season for Medicare scammers.

Here are some common ploys that Medicare scammers use to try and take advantage of seniors and ways to outsmart them:

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Medtronic (NYSE: MDT) has agreed to pay $9.9 million to settle a False Claims Act case brought by a whistleblower who claimed the company violated the Anti-Kickback Statute.

Medtronic, based in Minneapolis, Minnesota, is one of the world’s largest medical technology companies. Medtronic was founded in 1949, has over 46,000 employees and operates in 140 countries. According to Medtronic’s website, its Cardiac Rhythm Disease Management unit accounted for $5 billion, or approximately 30%, of Medtronic’s total $16.6 billion revenue in fiscal year 2013.

According to the Department of Justice, in 2009, a former Medtronic employee, Adolfo Schroeder, filed a lawsuit under the qui tam provisions of the False Claims Act alleging that Medtronic paid illegal kickbacks to physicians to induce them to implant in their patients pacemakers and defibrillators manufactured and sold by Medtronic. The government alleged that Medtronic violated the Anti-Kickback Statute which prohibits anyone from offering or paying anything of value to induce referrals of Medicare, Medicaid or any other patient covered by a Federal health care program.