Saturday, April 10, 2021

Fraud, waste and abuse in health care claims: A bad situation worsened by the pandemic Here's what benefits managers should know about detection and prevention. By Maria Turner | April 07, 2021 at 10:01 AM

https://www.benefitspro.com/2021/04/07/fraud-waste-and-abuse-in-health-care-claims-a-bad-situation-worsened-by-the-pandemic/?slreturn=20210310225936 

Two Miami-Dade pharmacy owners charged with stealing $8 million from drug companies BY JAY WEAVER APRIL 05, 2021 05:02 PM, UPDATED APRIL 06, 2021 09:09 AM

https://www.miamiherald.com/news/local/article250446181.html 

Teva, Pharmacies Want Humana's Copay Fraud Claims Tossed

https://www.law360.com/lifesciences/articles/1372162/teva-pharmacies-want-humana-s-copay-fraud-claims-tossed 

Lured by Free Shakes...

https://www.goerie.com/story/news/crime/2021/04/11/free-shakes-erie-weight-loss-scam-patients-targeted-55-m-scam/7160747002/ 

Another type of scheme involving compounding pharmacies and veterans

 U.S. Attorneys » Western District of Pennsylvania » News

Department of Justice
U.S. Attorney’s Office
Western District of Pennsylvania

FOR IMMEDIATE RELEASE
Thursday, April 8, 2021

3 Family Members Sentenced for Health Care Fraud Schemes Targeting Veterans

PITTSBURGH – Brothers Mehran David Kohanbash and Joseph Kohan, and their nephew, Nima Rodefshalom, have been sentenced for their roles in an elaborate fraud scheme that stole millions of dollars from health care systems across the United States.

United States District Judge Susan Paradise Baxter on Wednesday sentenced Nima Rodefshalom, 38, of Los Angeles, CA to 54 months’ imprisonment and today sentenced David Kohanbash, 53, of Beverly Hills, CA to 54 months’ imprisonment and Joseph Kohan, 62, of Encino, CA to 42 months’ imprisonment. The defendants pleaded guilty in December 2020 to charges of healthcare fraud, conspiracy to commit fraud, and conspiracy to violate the federal anti-kickback statutes. Additionally, 16 corporate entities (pharmacies) pled guilty to charges of healthcare fraud, conspiracy to commit fraud, and/or conspiracy to violate the federal anti-kickback statutes. Sentencing for the defendant pharmacies has not yet been scheduled. The defendants have already paid more than $60 million to the government as part of forfeiture and a civil settlement. As part of the sentence the Court ordered $54.5 million in restitution to compensate the health insurance companies that were defrauded, including the military health insurance entity, TRICARE.

According to the information presented to the Court at the time of the pleas the three defendants conspired together to execute health care fraud schemes that targeted patients that had undergone, or were to undergo, bariatric surgical procedures. The individual defendants together with the defendant pharmacies engaged in a series of interconnected actions that resulted in misleading advertising associated with supplying what were described to the Court as nutritional shakes; the inducement to enlist various patients in ordering the nutritional shakes resulted in the defendants and the pharmacies securing the patients’ insurance information which in turn resulted in the defendants (individual defendants and by and through the pharmacies) soliciting the patients to appeal to their respective physicians to prescribe what were described for the Court as High Yield (expensive) medications.

These medications were often compounded, meaning that one or more of the pharmacies mixed together preexisting medications or substances to provide a new or different product. It was a part of the scheme(s) involved in the guilty pleas that the defendants conspired to promote these medications that often yielded extremely high profits. It was a part of the healthcare fraud scheme that the defendants defrauded healthcare benefit programs, both private insurance carriers and the government run health care program, TRICARE, for military members and their families, by manipulating the

collection of co pays on various medications to make it appear that co pays were being collected when in fact they were not. An honest reporting of the failure to collect co pays would have resulted in the defendants being unable to bill insurance carriers for the cost of the various medications. The various schemes in which the defendants were involved were overlapping and ran from September of 2013 through May of 2018.

"Identifying and prosecuting individuals who exploit health care benefit programs for personal enrichment is a priority of our office," said Acting United States Attorney Stephen R. Kaufman. "The sentencings of these defendants to federal prison and the significant amount of forfeiture - the largest in District history - should serve as a sign of our commitment to pursue justice and preserve the integrity of health care benefit programs."

"With these sentencings, the defendants will now be held accountable for their intentions to defraud our healthcare system," said Acting Special Agent in Charge Carlton Peeples. "They’ll spend the next few years behind bars thinking about what their selfish actions cost them, the patients and our healthcare systems. This case involves $60 million in penalties and forfeiture. It’s the largest forfeiture in a criminal case in the history of the Western District of Pennsylvania. I commend the work of the agents involved in our Erie office, which worked this case tirelessly from beginning to end, while having limited resources and working the numerous other violations the FBI investigates. This case will have an impact nationwide and should also serve as a warning to other companies who choose to operate with fraud schemes instead of honesty. The FBI is committed to working with our federal and public sector partners to stop fraud and ensure everyone receives quality medical care."

"These sentences and monetary forfeitures demonstrate the commitment of the Defense Criminal Investigative Service, Federal Bureau of Investigation, Defense Health Agency, and the United States Attorney's Office in the Western District of Pennsylvania, to protect the American warfighter and taxpayer from those that attempt to victimize them by defrauding our nation's healthcare programs including TRICARE," said Bryan Denny, Patrick Hegarty, and Chris Dillard, Special Agents in Charge, U.S. Department of Defense Office of Inspector General, Defense Criminal Investigative Service. "False and inappropriate billings, by virtue of intended schemes or willful ignorance, place the American Warfighter in danger, erode public confidence and undermine the mission of our military services. DCIS and its law enforcement partners will continue to investigate healthcare fraud allegations in order to protect U.S. military members and the American taxpayer."

Assistant United States Attorneys Shardul S. Desai and James R. Wilson are prosecuting this case on behalf of the government.

The Federal Bureau of Investigation and the Department of Defense Office of the Inspector General conducted the investigation that led to the prosecution of Nima Rodefshalom, Mehran David Kohanbash, Joseph Kohan, Insure Nutrition, Inc., Affordable Pharmacy, Inc., ASC Pharmaceutical, LLC, DQD Enterprise Corporation, DTST Ventures, LLC, Econo Pharmacy, Inc., Emerson Pharmacy, Inc., Genorex Pharmaceutical, LLC, Nutrition Plus, Inc., Pharmatek Pharmacy, Inc., Premier Med Services, Inc., Rexford Pharmacy, Inc., Specialty Pharmacy Management of America, Inc., Solutech Pharmaceuticals, LLC, Village Drug & Compounding, Inc., and Vitamed LLC.

Topic(s): 
Health Care Fraud
Updated April 8, 2021

Tuscaloosa drug sales representative sentenced in health care fraud conspiracy

https://www.tuscaloosanews.com/story/news/crime/2021/04/08/tuscaloosa-man-sentenced-health-care-fraud-conspiracy/7126106002/ 

Tennesseean sentenced in insurance kickback scheme

Tennesseean sentenced in insurance kickback scheme: A Memphis medical device salesman who pleaded guilty in federal court in 2019 to paying kickbacks to generate sales of expensive compounded prescription drugs in an insurance fraud scheme was sentenced to 20 months in federal prison.

FDA Animal Drug Compounding

https://www.fda.gov/animal-veterinary/unapproved-animal-drugs/animal-drug-compounding

 

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Forward Regulatory Plan 2021-2023: Amendments to the ...

5 days ago — A new regulatory framework to address commercial compounding is being developed with the aim to fill a current gap in regulatory oversight.

 

Friday, April 2, 2021