Pfizer to Pay $14.5 Million for Illegal Marketing of Drug Detrol

Pfizer to Pay $14.5 Million for Illegal Marketing of Drug Detrol 
WASHINGTON - American pharmaceutical company Pfizer Inc. has agreed to pay $14.5 million to resolve False Claims Act allegations related to its marketing of the drug Detrol, the Justice Department announced today. The settlement resolves the last of a group of 10 qui tam, or whistleblower, suits that were filed in the District of Massachusetts and two other districts, beginning in 2003. The other nine suits were settled or dismissed in 2009 as part of the government's global resolution with Pfizer, under which the company agreed to pay $2.3 billion dollars to resolve civil claims and criminal charges regarding multiple drugs.

Mass. AG allege Medicaid fraud schemes cost $10M

Now imagine if the state actually went after Medicaid fraud in child welfare.

Mass. AG allege Medicaid fraud schemes cost $10M

BOSTON (AP) — Massachusetts Attorney General Martha Coakley announced indictments Friday against 10 people linked to a series of Medicaid fraud schemes that investigators say cheated taxpayers out of nearly $10 million.
The allegations included billing the state for care provided to dead patients, kickback schemes for unnecessary drug tests and claiming nursing home residents needed help walking and eating when they were able to do both on their own. In each case, investigators said the goal was to bilk MassHealth, the state's Medicaid program.
A total of 118 criminal indictments against 10 individuals have been handed down in the four cases.
Coakley said the indictments were returned Thursday by three grand juries including a special statewide grand jury and are the result of four major criminal investigations by the state Medicaid Fraud unit.
Coakley said the kind of fraud alleged in the indictments ultimately forces up health care costs for everyone in Massachusetts.
"It's like when people are shoplifting in a store, it's passed onto consumers," Coakley said Friday. "They might as well be walking over to MassHealth and taking money out of the state treasury."
The cases involved four private health care providers: Adlife Healthcare; Preventative Medicine Associates; Mitchell Counseling Services; and Wetterberg Nursing Homes, which ran the Pond View Nursing Facility in Boston.
In the case of Adlife, investigators allege that owner Sharon Richardson, 55, of Framingham and two employees billed MassHealth for approximately $5.5 million in services that were not provided.
Adlife is a group adult foster care provider for MassHealth with locations in Framingham, West Springfield, Boston and Hyannis.
Investigators' allege Adlife billed MassHealth for treating deceased individuals and individuals who never received services. Richardson is also accused of falsifying records submitted to MassHealth and working with two employees to destroy internal records to cover up the fraud.
Richardson was arrested Thursday. Her lawyer, Michael Stromsnes, declined comment.
The second set of indictments focus on a Brookline doctor, Punyamurtula Kishore, 61, and his company Preventative Medicine Associates, Inc., with 29 locations statewide.
Investigators said Kishore and three others orchestrated an elaborate drug screening kickback scheme and fraudulently billed MassHealth for nearly $3.8 million.
Coakley's office said Kishore used bribes to induce various so-called "sober homes" to send patients to his laboratories to perform unnecessary urine drug screens — as many as three a week — that were later billed to Medicaid. Investigators said drug screens are generally billed at between $100 and $200 each and Kishore billed MassHealth for tens of thousands of the tests.
Three managers or owners of the "sober homes" — New Horizon House in Boston, Marshall House in Malden and Gianna's House, which operates homes in Wareham, New Bedford and Sandwich — were also indicted.
Kishore was arraigned Wednesday in Malden District Court and later released after surrendering his passport.
Kishore's attorney said Kishore is "an extremely well-regarded member of the community" who denies the allegations.
The third alleged scheme defrauded MassHealth of $160,000 and involved David Benson, 48 of New Bedford and his company Mitchell Counseling Services.
Investigators said Benson, an independent clinical social worker, routinely billed for treatment that exceeded services provided to six patients. Coakley's office said Benson billed as if his patients were in need of acute care multiple times a week when they were being provided minimal care or no care at all.
A call to Mitchell Counseling Services wasn't answered Friday.
The final investigation resulted in an indictment against Carolyn Wetterberg, 70, of Weymouth for allegedly billing MassHealth more than $600,000 for services not provided.
Wetterberg was part owner and sole manager of Wetterberg Nursing Homes, Inc., which ran the Pond View Nursing Facility in the Jamaica Plain neighborhood of Boston. The 43-bed long term care facility was shut down by the Massachusetts Department of Public Health in June for poor quality of care.
Coakley's office said Wetterberg defrauded MassHealth by deliberately overstating the level of disabilities of those who lived in the facility, allowing her to bill for more than their care required.
Investigators said in some cases patients she claimed needed help walking were walking independently and those she claimed needed help eating were eating on their own.
A man who answered the phone at Wetterberg's home said she wasn't available for comment.

Pay may be hot issue, but other factors push harder on health costs

By Megan Woolhouse

Globe Staff / March 13, 2011

Blue Cross Blue Shield of Massachusetts has captured the public’s attention, although not the way it would have liked, as reports of millions paid to the insurer’s former chief executive and hefty stipends paid to board members sparked outrage.

The outcry grew big enough to force Blue Cross board members to vote to suspend their own payments and to lead the insurer to make promises to curb excessive payouts to executives. There’s just one problem: Those steps will do little to fix soaring health care costs.

“I have the same outrage,’’ Stuart H. Altman, a national health policy professor at Brandeis University, said about Blue Cross’s payments. But, “We need to put executive pay and board salaries in perspective. It is not the major force, or even close to the major force, in driving up health care costs.’’

US health care spending hit $2.5 trillion in 2009, increasing by about $600 billion from 2004, according to the Centers for Medicare and Medicaid Services. Nearly two-thirds of the increase was driven by rising costs in three areas: hospitals, which accounted for 33 percent of the increase; doctors, which accounted for 19 percent; and prescription drugs, which accounted for 10 percent.

Administrative costs, which would include payments to board members, accounted for about 5 percent of overall health care cost increases. Altman said Massachusetts health insurers spend about 10 percent on administrative costs, lower than the national average, which is typically 15 to 20 percent.

In a report last year, Attorney General Martha Coakley concluded that price increases by providers accounted for 90 percent of the growth in Massachusetts health care costs between 2006 and 2009. The report also found that prices varied widely, but the highest prices were charged by the biggest providers with market power to push insurers to pay more. Insurers, in turn, passed at least some of the those costs to consumers.

Health care costs are growing much faster than the economy and wages, the report warned.

“Such increases, if unchecked,’’ the report said, “threaten the financial stability of individuals and businesses, and the future viability of our gains in health care access.’’

Under the state’s universal health care law, about 98 percent of Massachusetts residents have insurance. Blue Cross is the state’s largest insurer, insuring more than 3 million residents.

Health care providers and insurers have long clashed over who was responsible for rising health care costs, leaving Massachusetts employers to deal with double-digit premium increases. Many firms criticized Blue Cross and other insurers for the relentless increases that crimp hiring by raising the costs of adding workers.

But it is the compensation issue that has provoked populist anger, as workers struggle with stagnant wages and rising health insurance costs.Continued...

Massachusetts Investigation of Health Care Cost Trends and Cost Drivers

Massachusetts Investigation of Health Care Cost Trends and Cost Drivers