The United States Attorney’s Office alleges serious Medicare fraud and abuse claims in a recent qui tam lawsuit, stating that a number of different healthcare companies had submitted false claims to Medicare and Tricare.

The Medicare fraud and abuse allegedly consisted of submitting false claims asking for compensation for pain relieving injections, which were reportedly never given to patients.

The qui tam lawsuit names Franklin-based Pain MD LLC and affiliated companies as defendants, along with their owners Michael Kestner and Lisabeth Smolenski Williams, accusing them of committing Medicare fraud and abuse.

According to the qui tam lawsuit, Kestner and Williams and their associates submitted claims for single tendon origin injections “that they knew or should have known were not provided to patients.”

Overview of Medicare Fraud and Abuse Allegations

According to the qui tam lawsuit, Kestner and Williams’ alleged scheme lasted from at least 2010 to October 2018. It started with building and operating pain management clinics in Tennessee, North Carolina, and Virginia, which allegedly submitted false claims for tendon origin injections, or TOIs.

These injections are commonly implemented to treat tendonitis and similar painful conditions, which are widely covered by Medicare or Tricare. However, certain injections like trigger point injections can only be given four times a year under these federal healthcare programs.

According to the lawsuit, these injections were not actually shot into patients’ tendons so they received no help for their pain. According to the qui tam lawsuit, patients allegedly received back injections instead of the tendon injections that were charged for in the Medicare claims.

Kestner and Williams had allegedly recruited medical providers, nurse practitioners, and physician’s assistants for their pain clinics. They then allegedly trained and pressured them into giving a high number of injections into patients back muscles; the bills stated they had received TOI injections.

Kestner and Williams allegedly pressured recruits into meeting a TOI billing rate that was within 15 percent of the top biller of this kind of injection. This unrealistic goal allegedly caused their healthcare workers to give six to eight injections per visit, and sometimes as many as 12 injections into patients’ back muscles.

Each of these injections was reportedly billed as TOIs, which the DOJ says is considered serious Medicare fraud and abuse.

These alleged false claims to Medicare and Tricare have allegedly resulted in millions of dollars in payments to Kestner and Williams, with Medicare paying approximately $3 million for allegedly false claims from June 1, 2010 through Dec. 31, 2015. According to the qui tam lawsuit Tricare had paid one of their companies, Pain MD, approximately $288,000 in compensation for allegedly false claims.

Medicare Fraud

Medicare fraud and abuse occur when a healthcare provider, company, or professional files a claim for services that were either not performed or were performed by unqualified professionals. Medicare fraud and abuse can come in a number of different forms, including but not limited to:

• Fraudulent Upcoding in Medical Billing
• Illegal Kickback Arrangements with Hospitals
• Overcharging for Medical Goods or Services
• Providing Medical Services not Medically Necessary

Whistleblowers help recover millions of dollars
in taxpayers’ money, and are one of the most important tools in stopping defrauding of the federal government, ensuring that Medicare, Tricare, and Medicaid patients receive sufficient medical care.

People who witness fraud against the federal government and report it could receive 15 to 30 percent of any settlement awarded for their role as a whistleblower.