News: DOJ intervenes in Integra $129 million Medicare whistleblower suit

A whistleblower lawsuit filed by Integra Med Analytics, LLC against a New York-based group of skilled nursing facilities (SNF) was made public when the U.S. Department of Justice (DOJ) intervened to prosecute the action for the first time ever. The lawsuit alleges that the 11 SNFs in the group have been fraudulently billing Medicare for unnecessary services for over a decade, resulting in over $129 million in fraud.

Integra applies statistical analysis of data sets to detect fraud, then files cases under the False Claims Act (FCA), which allows private party whistleblowers to file a case on the government’s behalf if the government is being defrauded. In most cases, whistleblowers are firsthand witnesses to the alleged fraud, but Integra identifies potential fraud through mathematical modeling.

There have been three previous, similar FCA lawsuits filed by Integra; however, all have been unsuccessful based on arguments that the company couldn’t provide enough detail about the specifics of the alleged fraud. Integra also based its previous accusations on publicly available documents, which goes against the FCA’s public disclosure bar that says whistleblower lawsuits cannot be based on information that is broadly/publicly available and takes no expertise to interpret.

This new support by the DOJ, however, may be a change of pace from Integra’s previously failed lawsuits. Following its own investigation of Integra’s allegations, the DOJ has filed its own complaint-in-intervention alleging that the fraud identified by Integra continued through the year 2019.

Editor’s note: The Integra lawsuit can be found here. The DOJ press release can be found here. Additional ACDIS coverage of Integra lawsuits can be found here. The implications of similar lawsuits on healthcare and CDI can be found here.