Health Care Fraud Sample Clauses

Health Care Fraud. From at least January 2005 through September 2009, XXXXX knowingly and willfully defrauded health care benefit programs, as defined by federal law, by causing claims for illegal prescriptions to be submitted to and paid by health care benefit programs. XXXXX, an osteopathic physician, issued prescriptions for Schedule II controlled substances, including OxyContin and oxycodone, that were not in the usual course of medical practice, for persons with whom he had no legitimate physician-patient relationship and who had no legitimate medical need for the prescriptions. These prescriptions for Schedule II controlled substances issued by XXXXX were filled by persons who illegally used or distributed the controlled substances. The pharmacies that filled the illegal prescriptions issued by XXXXX submitted claims for payment to health care benefit programs, including Medicare, Medicaid (a/k/a Missouri HealthNet), TriCare, Blue Cross Blue Shield- Kansas City, and United Healthcare. The pharmacies received payment from these health care benefit programs. The details of this health care fraud scheme are as follows:
Sample 1Sample 2
AutoNDA by SimpleDocs
Health Care Fraud. Prescriptions in XXXXXXXX’ Name. From at least January 2006 through April 2009, XXXXXXXX knowingly and willfully defrauded federal health care benefit programs by causing claims for illegal prescriptions issued in his name to be submitted to and paid by federal health care benefit programs. XXXXXXXX obtained prescriptions for Schedule II controlled substances from Xxxxx Xxxxx (Xxxxx), an osteopathic physician. XXXXXXXX obtained these prescriptions from Xxxxx, knowing that he had no legitimate medical need for these prescriptions and that they would be filled and the drugs used for illegal purposes. Medicare Part D is a health care benefit program under federal law. XXXXXXXX was a Medicare Part D beneficiary and used his Medicare Part D benefits to, among other things, fill prescriptions. The pharmacies that filled the illegal prescriptions for XXXXXXXX submitted claims for payment to Medicare Part D, and the pharmacies received payment. From September 14, 2006 through Prescriptions in the Names of Co-Conspirators. Furthermore, from at least October 2006 through May 2009, XXXXXXXX knowingly and willfully defrauded federal health care benefit programs by causing claims for illegal prescriptions issued in the names of co-conspirators to be submitted to and paid by federal health care benefit programs. XXXXXXXX introduced co-conspirators to Xxxxx so that the co-conspirators could obtain prescriptions for Schedule II controlled substances from Xxxxx. XXXXXXXX caused the co-conspirators to obtain these prescriptions, knowing that the prescriptions were not for a legitimate medical need, and would be filled and the drugs used for illegal purposes. The co- conspirators filled the prescriptions and gave some or all of the Schedule II controlled substances to XXXXXXXX who then illegally distributed them. Co- conspirators Xxxxx Xxxxxx and Xxxxxx Xxxxxx were Medicare Part D beneficiaries. XXXXXXXX caused prescriptions in Xxxxx Xxxxxx’x and Xxxxxx Xxxxxx’x names to be filled at pharmacies using their Medicare Part D benefits. The pharmacies that filled the illegal prescriptions submitted claims for payment to Medicare Part D, and the pharmacies received payment. From March 20, 2007 through July 20, 2007, XXXXXXXX caused Xxxxx Xxxxxx and Xxxxxx Xxxxxx to submit 12 claims for illegal prescriptions to Medicare Part D. These claims were for 1,800 Schedule II pills. Medicare Part D paid $7,391 on those claims for illegal prescriptions. Co-conspirators Xxxx XxXxxxxx, XxXxx X...
Sample 1
Health Care Fraud. Under federal law, a health care benefit program is a public or private plan or contract, affecting commerce, under which any medical benefit, item, or service is provided to any individual, and includes any individual or entity who is providing a medical benefit, item, or service for which payment may be made under the plan or contract. Medicare, Medicaid, and Tricare are health care benefit programs under federal law. In addition, private insurance companies, third party administrators, and self-funded healthcare plans administered by an employer may also be health care benefit programs under federal law. HCA was out of network and non-participating with all or nearly all health care benefit programs. Typically, patients who sought treatment at HCA paid in advance, and then HCA submitted claims for reimbursement to the health care benefit program on behalf of the patient. HCA used the American Medical Association’s Current Procedural Terminology, known as CPT codes, to submit claims for reimbursement to health care benefit programs. Health care benefit programs require providers such as HCA to keep written medical records that accurately reflect patient histories, pertinent findings, examination and test results, and recommendations for services to be rendered. These written records must document the support for the submitted claims, and health care benefit programs are allowed to review the patient’s file to determine whether the claim is, in fact, supported. Defendants engaged in fraudulent billing by “upcoding” and falsifying claims submitted to health care benefit programs in an effort to be paid more than the amount to which HCA was entitled. Variations on defendants’ health care fraud scheme included:1 i. Billing for physician office visits when XXXXX XXXXX was out of town ii. Billing for physician office visits when XXXXX XXXXX had little or no involvement with the patient iii. Billing for physician office visits when the patient contact was by telephone call iv. Billing for physician-supervised IV services when no physician was on duty at the clinic
Sample 1

Related to Health Care Fraud

  • Health Care Operations “Health Care Operations” shall have the same meaning as the term “health care operations” in 45 CFR §164.501.

  • Health Care Coverage The Company shall continue to provide Executive with medical, dental, vision and mental health care coverage at or equivalent to the level of coverage that the Executive had at the time of the termination of employment (including coverage for the Executive’s dependents to the extent such dependents were covered immediately prior to such termination of employment) for the remainder of the Term of Employment, provided, however that in the event such coverage may no longer be extended to Executive following termination of Executive’s employment either by the terms of the Company’s health care plans or under then applicable law, the Company shall instead reimburse Executive for the amount equivalent to the Company’s cost of substantially equivalent health care coverage to Executive under ERISA Section 601 and thereafter and Section 4980B of the Internal Revenue Code (i.e., COBRA coverage) for a period not to exceed the lesser of (A) 18 months after the termination of Executive’s employment or (B) the remainder of the Term of Employment, and provided further that (1) any such health care coverage or reimbursement for health care coverage shall cease at such time that Executive becomes eligible for health care coverage through another employer and (2) any such reimbursement shall be made no later than the last day of the calendar year following the end of the calendar year with respect to which such coverage or reimbursement is provided. The Company shall have no further obligations to the Executive as a result of termination of employment described in this Section 8(a) except as set forth in Section 12.

  • Health Care Matters Without limiting the generality of any representation or warranty made in Article 7 or any covenant made in Articles 8 or 9, each Borrower represents and warrants on a joint and several basis to and covenants with the Administrative Agent and each Lender, and shall be deemed to represent, warrant and covenant on each day on which any advance or accommodation in respect of any Loan is requested or made or any Liabilities shall be outstanding under this Agreement (or any Affiliate Term Loan Liabilities shall be outstanding under the Term Loan Agreement), that:

  • HEALTH CARE PLANS ‌ Notwithstanding the references to the Pacific Blue Cross Plans in this article, the parties agree that Employers, who are not currently providing benefits under the Pacific Blue Cross Plans may continue to provide the benefits through another carrier providing that the overall level of benefits is comparable to the level of benefits under the Pacific Blue Cross Plans.

  • Health Care Benefits A. Each regular, full-time employee may elect coverage for himself and his eligible dependents* under one of the following health insurance plans: 1. Blue Cross/Blue Shield of Michigan Flexible Blue 3 with Flexible Blue Rx Prescription Drug Coverage with a Health Savings Account (hereinafter collectively referred to as the “H.S.A Plan”). The Employer shall pay for the illustrated premium cost of this coverage and make an annual contribution to each participating employee’s Health Savings Account in the amount of $500 for those selecting single coverage and $1,000 for those selecting Employee & Spouse, Employee Child(ren) or Family coverage, or the maximum annual amount the Employer is permitted to pay under Section 3 of the Publicly Funded Health Insurance Contribution Act, Public Act 152 of the Michigan Public Acts of 2011, whichever results in the lesser Employer contribution to the cost of such plan. Employees may, at their option, make additional contributions through bi-weekly pre-tax payroll deduction as permitted by applicable law. 2. Blue Cross/Blue Shield of Michigan Community Blue PPO Option 3 Revised Plan with Blue Preferred Rx Prescription Drug Coverage with a 50% co-pay ($5 floor and a $50 ceiling). Employees shall pay the difference between the illustrated premium cost of this coverage and the amount of the Employer’s total contribution towards the cost of coverage under the H.S.A. Plan as described in Section 1 (a) (1), for the same level of benefit (i.e. single, employee/spouse, employee/child(ren) and family), or pay the difference between the total cost of such coverage and the maximum annual amount the Employer is permitted to pay under Section 3 of the Publicly Funded Health Insurance Contribution Act, Public Act 152 of the Michigan Public Acts of 2011, whichever results in the greater employee contribution. 3. Blue Cross/Blue Shield of Michigan Community Blue PPO Option 6 Revised Plan with Blue Preferred Rx Prescription Drug Coverage with a 50% co-pay ($5 floor and a $50 ceiling). Employees shall pay the difference between the illustrated premium cost of this coverage and the amount of the Employer’s total contribution towards the cost of coverage under the H.S.A. Plan as described in Section 1 (a) (1), for the same level of benefit (i.e. single, employee/spouse, employee/child(ren) and family), or pay the difference between the total cost of such coverage and the maximum annual amount the Employer is permitted to pay under Section 3 of the Publicly Funded Health Insurance Contribution Act, Public Act 152 of the Michigan Public Acts of 2011, whichever results in the greater employee contribution. (a) All coverage under any of the foregoing plans shall be subject to such terms, conditions, exclusions, limitations, deductibles, co-payments premium cost-sharing, and other provisions of the plans. Coverage shall commence on the employee’s ninetieth (90th) day of continuous employment. The employee’s contribution to the cost of such coverage shall be payable on a bi-weekly basis through automatic payroll deduction. (b) To qualify for health care benefits as above described each employee must individually enroll and make proper application for such benefits at the Human Resources Department upon the commencement of his regular employment with the Employer. (c) Except as otherwise provided under the Family and Medical Leave Act, when on an authorized unpaid leave of absence of more than two weeks, the employee will be responsible for paying all his benefit costs for the period he is not on the active payroll. Proper application and arrangements for the payment of such continued benefits must be made at the Human Resources Department prior to the commencement of the leave. If such application and arrangements are not made as herein described, the employee's health care benefits shall automatically terminate upon the effective date of the unpaid leave of absence. (d) Except as otherwise provided under this Agreement and/or under COBRA, an employee's health care benefits shall terminate on the date the employee goes on a leave of absence for more than two weeks, terminates, retires or is laid off. Upon return from a leave of absence or layoff, an employee's health care benefits coverage shall be reinstated commencing with the employee's return. (e) An employee who is on layoff or leave of absence for more than two weeks or who terminates may elect under COBRA to continue the coverage herein provided at his own expense. (f) The Employer reserves the right to change a carrier(s), a plan(s), and/or the manner in which it provides the above benefits, provided that the benefits and conditions are equal to or better than the benefits and conditions outlined above. (g) To be eligible for health care benefits as provided above, an employee must document all coverage available to him under his spouse's medical plan and cooperate in the coordination of coverage to limit the Employer's expense. If an employee’s spouse or eligible dependent children work for an employer who provides medical coverage, they are required to elect medical coverage with their employer, so long as the spouse’s or monthly contribution to the premium does not exceed 20% of the total premium cost of said coverage. The Monroe County Plan shall provide secondary coverage. (h) Each employee is responsible for notifying the Human Resources Department of any change in his status, which might affect his insurance coverage or benefits, such as, marriage, divorce, births, adoptions, deaths, etc.

  • Health Care Compliance Neither the Company nor any Affiliate has, prior to the Effective Time and in any material respect, violated any of the health care continuation requirements of COBRA, the requirements of FMLA, the requirements of the Health Insurance Portability and Accountability Act of 1996, the requirements of the Women's Health and Cancer Rights Act of 1998, the requirements of the Newborns' and Mothers' Health Protection Act of 1996, or any amendment to each such act, or any similar provisions of state law applicable to its Employees.

  • Health Care Laws The Company and each of its subsidiaries is, and at all times has been, in compliance in all material respects with all applicable Health Care Laws, and has not engaged in activities which are, as applicable, cause for false claims liability, civil penalties, or mandatory or permissive exclusion from Medicare, Medicaid, or any other state health care program or federal health care program. For purposes of this Agreement, “Health Care Laws” means: (i) the Federal Food, Drug, and Cosmetic Act, (ii) all applicable federal, state, local and foreign health care related fraud and abuse Laws, including, without limitation, the U.S. Anti-Kickback Statute (42 U.S.C. Section 1320a-7b(b)), the U.S. Physician Payment Sunshine Act (42 U.S.C. Section 1320a-7h), the U.S. Civil False Claims Act (31 U.S.C. Section 3729 et seq.), the criminal False Claims Law (42 U.S.C. Section 1320a-7b(a)), all criminal Laws relating to health care fraud and abuse, including but not limited to 18 U.S.C. Sections 286 and 287, and the health care fraud criminal provisions under the U.S. Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) (42 U.S.C. Section 1320d et seq.) as amended by the Health Information Technology for Economic and Clinical Health Act (42 U.S.C. Section 17921 et seq.), the exclusion laws (42 U.S.C. Section 1320a-7), the civil monetary penalties law (42 U.S.C. Section 1320a-7a), (iii) Medicare (Title XVIII of the Social Security Act); (iv) Medicaid (Title XIX of the Social Security Act), (v) the Controlled Substances Act (21 U.S.C. Sections 801 et seq.), (vi) Healthcare Product Laws, including but not limited to HIPAA, relating to data privacy and the protection of personal information, including personal health information, and (vii) any and all other applicable health care laws and regulations. Neither the Company nor any of its subsidiaries has received written notice of any claim, action, suit, proceeding, hearing, enforcement, audit, investigation, arbitration or other action from any court, arbitrator, other Governmental Authority or third party alleging that any product, operation or activity of the Company or a subsidiary is in material violation of any Health Care Laws, and, to the Company’s knowledge, no such claim, action, suit, proceeding, hearing, enforcement, audit, investigation, arbitration or other action is threatened. Neither the Company nor any of its subsidiaries are a party to or have any ongoing reporting obligations pursuant to any corporate integrity agreements, deferred prosecution agreements, monitoring agreements, consent decrees, settlement orders, plans of correction or similar agreements with or imposed by any Regulatory Agency or other Governmental Authority. Neither the Company, any of its subsidiaries, any of their respective directors, officers, nor, to the Company’s knowledge, any of their respective employees or agents has been excluded, suspended or debarred from participation in any U.S. federal health care program or human clinical research or, to the knowledge of the Company, is subject to an inquiry, investigation, proceeding, or other similar action by any Governmental Authority that would reasonably be expected to result in debarment, suspension, or exclusion.

  • Medicare Parts A and B of the health care program for the aged and disabled provided by Title XVIII of the United States Social Security Act, as amended from time to time. [MEMBER]. An eligible person who is covered under this Contract (includes Covered Employee[ and covered Dependents, if any)].

  • Health Care Insurance While a faculty member is on an approved leave of this type, the faculty member will be advised regarding the right to continue health care benefits in accordance with COBRA during the period of unpaid absence.

  • Health Care The Company will reimburse the Executive for the cost of maintaining continuing health coverage under COBRA for a period of no more than 12 months following the date of termination, less the amount the Executive is expected to pay as a regular employee premium for such coverage. Such reimbursements will cease if the Executive becomes eligible for similar coverage under another benefit plan.

Draft better contracts in just 5 minutes Get the weekly Law Insider newsletter packed with expert videos, webinars, ebooks, and more!