A Georgia doctor and her practice group have agreed to pay approximately $1,850,000 to resolve allegations that they violated the False Claims Act by, among other things, billing the government for cataract surgeries and diagnostic tests that were not medically necessary, tests that were incomplete or of worthless value, and office visits that did not provide the level of service claimed.
The settlement resolves allegations that the doctor knowingly submitted false claims to federal healthcare programs for medically unnecessary cataract extraction surgeries and YAG laser capsulotomies. The government alleged that the doctor performed these procedures on patients that did not qualify for the procedure under accepted standards of medical practice and, in some cases, caused injury to her patients. Additionally, the government alleged that the doctor falsely diagnosed patients with glaucoma to justify unnecessary diagnostic testing and treatment that was billed to Medicare. The government alleged that many of the diagnostic tests that she ordered were not properly performed, were performed on a broken machine, or were not interpreted in the medical record, as required by Medicare.
The settlement resolves allegations in a lawsuit filed by a former employee of the doctor under the qui tam, or whistleblower, provisions of the False Claims Act (FCA).
To protect federal healthcare programs and beneficiaries going forward, the doctor and her practice group have entered into a detailed, multi-year Integrity Agreement and Conditional Exclusion Release (IA) with OIG that is more robust than OIG’s standard agreement. The IA includes training and reporting requirements and enhanced material breach provisions. The IA also requires the doctor to hire an Independent Review Organization to conduct annual claims reviews to determine whether the items and services furnished were medically necessary and appropriately documented, and whether the claims were correctly coded, submitted, and reimbursed. OIG did not release its permissive exclusion authority and will provide such a release only after the doctor and her practice group have satisfied their obligations under the IA.
Compliance Perspective
Issue
It is illegal to submit claims for payment to Medicare or Medicaid that you know or should know are false or fraudulent. Filing false claims may result in fines of up to three times the programs’ loss plus $11,000 per claim filed. Under the civil False Claims Act, each instance of an item or a service billed to Medicare or Medicaid counts as a claim, so fines can add up quickly. Facility staff should be knowledgeable in how to report suspicious billing practices. A nonretaliatory environment for reporting suspicious billing practices is mandatory for all facilities.
Discussion Points
- Review your policies and procedures for preventing and reporting a false claim and for conducting a Triple Check Process to verify accuracy of Medicare claims. Ensure that your policies are reviewed at least annually and updated when new information becomes available.
- Train all staff upon hire and at least annually on your compliance and ethics policies and procedures and on what can be considered a false claim. Provide training to appropriate staff on the Triple Check Process for ensuring accuracy of all Medicare billing and supporting documentation before claims are submitted. Document that these trainings occurred and file the signed document in each employee’s education file.
- Periodically perform audits to ensure all staff are aware of compliance and ethics concerns and understand their responsibility to report any potential compliance and ethics violations to their supervisor, the compliance and ethics officer, or via the anonymous hotline. Audit to ensure that the Triple Check Process is being followed each month before claims are submitted to Medicare, and that any identified irregularities are corrected.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
