By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law
Southeast Orthopedic Specialists (SOS), located in Jacksonville, Florida, agreed to pay $4,488 million on December 7, 2016, to settle allegations that it violated the False Claims Act (FCA) by allegedly billing federal health care programs for millions of dollars for unnecessary services.
Protection of Federal Health Care Programs.
U.S. Attorney A. Lee Bentley III of the Middle District of Florida made the announcement. In the statement he said: “The United States Attorney’s Office is committed to taking the steps necessary to protect Medicare and other federal health care programs from fraud. When health care practitioners submit fraudulent claims for reimbursement, we will hold them accountable.”
The U.S. Department of Justice (DOJ) said that SOS submitted claims for payment declaring that a physician had been present during the patient visits, even when there was not really one there. The medical center also billed Medicare for ultrasound-guided injections that were unnecessary, it was alleged.
SOS Modified Its Billing.
According to the allegations, a billing modifier was used by SOS that showed separate evaluations and management (E&M) services were performed, while in reality, those services were not separate. This resulted in higher payments by Medicare. SOS also used a modifier that showed two procedures were conducted, when the procedures should have been billed together as one. This is known as “unbundling.”
According to the allegations, sometimes a third modifier was used by SOS to falsely surpass the Medicare cap on physical therapy, even though there was no medical need for it.
The prosecutors stated that SOS also scheduled for patient follow-ups 12 to 14 weeks after the operative visits. This allowed SOS to avoid Medicare’s 90-day diagnosis-related group charge. Because of this, SOS was able to receive a greater reimbursements.
The Government Is More Aggressively Fighting Health Care Fraud.
This FCA settlement reveals the emphasis the government is putting on fighting health care fraud. It marks yet another achievement for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative. FCA recoveries reached an all time high during the previous year and the government is expected to continue to pursue these claims.
Special Agent in Charge Shimon Richmond is reported to have stated, “The Department of Health and Human Services, Office of Inspector General will relentlessly seek out those who defraud the Medicare program. Obtaining tax dollars which Medicare providers are not entitled to impact our entire healthcare system and the OIG will hold health care providers accountable who misrepresent services to boost profits.”
Contact Experienced Health Law Attorneys.
The Health Law Firm routinely represents pharmacists, pharmacies, physicians, nurses and other health providers in Centers for Medicare and Medicaid Services (CMS) investigations, Medicare Audit defense, regulatory matters, licensing issues, litigation, inspections and audits involving the DEA, Department of Health (DOH) and other law enforcement agencies. Its attorneys include those who are board certified by The Florida Bar in Health Law as well as licensed health professionals who are also attorneys.
To contact The Health Law Firm, please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.
“United States Settles False Claims Act Allegations Against Orthopedic Surgery Practice For $4,488,000.” United States Department of Justice. (December 7, 2016). Web.
Pelican, Garret. “Feds Settle Health Care Fraud Case For $4.5 Million.” The Florida Times. (December 7, 2016). Web.
Kass, Dani. “Fla. Orthopedic Center Pays $4.5M To End FCA Claims.” Law360. (December 7, 2016). Web.
About the Author: George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law is an attorney with The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Avenue, Altamonte Springs, Florida 32714, Phone: (407) 331-6620.
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