A series of criminal and civil enforcement actions announced in recent weeks demonstrate the continued attention that state regulators throughout the Northeast are placing on health care fraud. These actions, and the significant sanctions imposed by courts and the government, can serve as a reminder that violators of health care fraud laws are subject to scrutiny at both the federal and state levels (often simultaneously), and that such violations can create exposure to significant civil and criminal penalties.

In Massachusetts, a pain management physician was sentenced on March 22, 2018 to eight years in prison and ordered to pay restitution in excess of $8 million dollars after pleading guilty to 27 counts of health care fraud, conspiracy to commit mail fraud and money laundering. According to the U.S. Attorney’s Office for the District of Massachusetts, the physician over-scheduled patients to increase reimbursement opportunities, conducted cursory patient examinations, and falsely billed Medicare for medical services that were not provided, but also prescribed large doses of opiate prescriptions that led to the physician being one of the highest-volume prescribers of oxycodone in Massachusetts (behind only a Boston hospital). The physician allegedly entered false entries into patients’ medical records (or had employees do so on his behalf), and made false representations concerning services provided in submissions to Medicare and private insurance companies. Finally, the physician also allegedly billed Medicare and private insurers for urine drug testing that was false and fraudulent, including by conducting duplicate testing in violation of Medicare billing rules, by running tests on analyzers that had not been properly calibrated and validated, and by falsifying urine drug test results.

On March 28, 2018 New York Attorney General Eric Schneiderman announced a joint state-federal $10.3 million dollar settlement with CenterLight Health System, Inc. and CenterLight Healthcare, Inc. to resolve alleged violations of the New York and federal False Claims Acts. The settlement arises from allegations that CenterLight’s former managed long-term care plan in New York submitted fraudulent requests to the New York Medicaid program for monthly capitation payments for 186 individuals not eligible to receive coverage under the plan, and then knowingly avoided its obligation to refund those amounts to the Medicaid program. The settlement will be split between the State of New York and the federal government, as well as the whistleblower who initiated the case.

The above was the second joint state-federal settlement reached in March by the Office of the Attorney General in New York. On March 7, a pediatrics practice based on Long Island, NY and various current and former physician-partners of the practice agreed to a $750,000 settlement with the Attorney General to resolve allegations that certain of the practice’s employees billed Medicaid without being enrolled as providers in the New York Medicaid program. According to the Attorney General, the practice allegedly did not routinely enroll its employee providers in the Medicaid program, and instead billed for services provided by un-enrolled providers under the Medicaid provider numbers of the physician-partners of the practice, and thus submitted false or fraudulent claims to the New York Medicaid program.

Finally, in Connecticut, the Division of Criminal Justice announced on March 20, 2018 that a woman had been sentenced to more than five years in prison, and ordered to pay over $600,000 in restitution, after pleading guilty to larceny by defrauding a public community and identity theft in connection with her use of a relative’s name to bill Medicaid for therapy services. According to the announcement, the defendant allegedly used a relative’s name and credentials to bill Medicaid for therapy services that she was not licensed to provide, or that she never provided.