United States Attorney A. Lee Bentley, III announced on December 7, 2016, that Southeast Orthopedic Specialists (SOS), a Jacksonville, Florida-based orthopedic medical group, has agreed to pay the government $4.488 million to resolve allegations that it violated the False Claims Act.
The settlement stems from the United States claiming that Southeast Orthopedic Specialists billed government healthcare programs for services that were not medically necessary and reasonable. According to a DoJ press release, the United States alleges that Southeast Orthopedic Specialists sought reimbursement for millions of dollars of healthcare claims that were questionable, including:
1. SOS certified that it met certain standards related to the “meaningful use” of electronic health records when the practice had, in fact, not met those standards;
2. SOS knowingly billed for certain claims as “incident to” physician supervision when no physician was present or there was no verification of any physician being present;
3. SOS knowingly billed for certain claims using Modifier 25 signifying that a separate evaluation and management service was performed even when there was no such separate service;
4. SOS knowingly billed for certain claims using Modifier 59 signifying that two procedures, rather than one, were billable even when these procedures should have more appropriately been billed as one such procedure;
5. SOS knowingly scheduled patients’ follow-up operative visits from 12 weeks following surgery to 14 weeks in an effort to bill for a separate visit outside the normal Medicare 90 days Diagnosis-Related Group charge;
6. SOS knowingly used and billed for ultrasound-guided injections routinely even in the absence of medical necessity; and
7. SOS knowingly billed for certain physical therapy claims using Modifier KX so as to exceed the Medicare cap on physical therapy, despite the absence of medical necessity.
“The United States Attorney’s Office is committed to taking the steps necessary to protect Medicare and other federal health care programs from fraud,” said U.S. Attorney Bentley. “When health care practitioners submit fraudulent claims for reimbursement, we will hold them accountable.”
This settlement illustrates the government’s emphasis on combating health care fraud and marks another achievement for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced in May 2009 by the Attorney General and the Secretary of Health and Human Services. Under the qui tam provisions of the False Claims Act, private citizens with knowledge of similar fraud against the government can bring a lawsuit on behalf of the government and are entitled to share in any recovery. The False Claims Act allows the government to recover up to three times the amount fraudulently billed by the defendants as well as monetary penalties for each false claim. Private citizens who bring cases on behalf of the government are known as relators and are entitled to receive between 15-30 percent of the government’s recovery as well as their attorney’s fees.
To learn more about the False Claims Act, click here.