On November 22, 2019, the United States Attorney Office for the Southern District of New York (USAO) announced that an ophthalmologist with practices in New York and Connecticut has been indicted for healthcare fraud. The USAO also filed a civil fraud complaint against the physician and his medical practice under the False Claims Act.
The indictment alleges that between 2010 and 2017, the physician engaged in fraudulently billing patients, Medicare, and private insurance programs millions of dollars for complex eye surgeries that were not actually performed. The civil complaint further alleges that the physician and his practice engaged in widespread healthcare fraud by consistently “upcoding” surgical procedures, examinations, and tests in fraudulent billings submitted to Medicare and Medicaid. It is also alleged that patient records were falsified, employees of the practice were pressured to participate in the scheme, and draconian debt collection proceedings were implemented against patients who did not pay the full amount of the fraudulently billed charges.
The civil complaint alleges that over a seven-year period, beginning in 2010, the defendant knowingly submitted, or caused to be submitted, claims for reimbursement to government payors for medical services that (i) were not actually performed; (ii) were not documented in the medical records; (iii) were not medically necessary; and/or (iv) failed to otherwise comply with Medicare and Medicaid rules and regulations. These actions allegedly caused the government to be billed for thousands of false or fraudulent claims. The government further alleges that the defendants engaged in widespread healthcare fraud by consistently “upcoding” surgical procedures, examinations, and tests to maximize the reimbursement. In order to justify the claims, the government alleges that medical records were falsified, resulting in inaccurate patient diagnoses and operative reports that falsely described the procedures performed on patients.
In addition to the criminal charges, and pursuant to the False Claim Act 31 U.S.C. §§ 3729 et seq., the government is seeking civil money damages in the form of treble damages (three times the amount paid by the government) plus civil per claim penalties. It is likely that if found guilty, the government may impose additional sanctions such as revocation of Medicare billing privileges and/or exclusion from participation in any government-funded program.
This indictment and civil complaint are yet another indication that the government’s investigation and prosecution of healthcare providers are continuing unabated. Non-compliance with Medicare and Medicaid rules can lead to a myriad of legal problems for providers, including criminal prosecution. All providers, including physicians, dentists, hospitals, pharmacies, laboratories, and others, should review their billing and coding practices and perform a top-to-bottom review of their overall operations. A compliance strategy that includes a good-faith review of a provider’s operations combined with remedial measures of suspect activities is a prudent approach to avoid regulatory enforcement actions by the government.
Frier Levitt maintains an interdisciplinary team of attorneys experienced in criminal and civil investigations—including attorneys from our white-collar criminal, regulatory healthcare and life sciences, and litigation practice groups—that can assist providers in evaluating and mitigating the risks of government investigations. Additionally, our team has successfully secured dozens of settlements with the Department of Justice and Self-Disclosures with the Office of the Inspector General. Many of these settlements have limited the severity of the enforcement by the government.
Contact Frier Levitt today for a confidential discussion with one of our attorneys to determine your risk of regulatory scrutiny and potential solutions.