Acting United States Attorney Steve Butler, of the Southern District of Alabama, announced last week that Dr. James M. Crumb, a Physical Medicine and Rehabilitative specialist currently practicing in Mobile, Alabama as Mobility Metabolism and Wellness, P.C. (MMW), and Coastal Neurological Institute, P.C. (CNI), a local neurosurgeon physician group, collectively paid $1.4 million to resolve allegations that they violated the False Claims Act (“FCA”) by engaging in fraudulent schemes to maximize payment from the Medicare, Medicaid, and TRICARE health care programs.
“Our office will protect federal health care programs by pursuing providers who bill for medically unreasonable and unnecessary services and engage in fraudulent billing practices to seek payments to which they are not entitled,” said Acting United States Attorney Butler. “We must prevent fraud, waste, and abuse of the Medicare, Medicaid, and Tricare programs as taxpayer dollars are at stake.”
In late December 2015, the United States Attorney’s Office filed a civil lawsuit against Defendants CNI, Crumb, and MMW, on behalf of the Department of Health and Human Services and the Department of Defense. The United States alleged that the Defendants knowingly billed federal health care programs for medically unreasonable and unnecessary ultrasound guidance used with routine lab blood draws, and with Botox and trigger point injections. The United States further alleged that CNI, Crumb, and other CNI physician employees unnamed in the lawsuit, knowingly manipulated billing codes in order to circumvent safeguards implemented by Medicare’s National Correct Coding Initiative to combat improper and fraudulent duplicate claim line billing of certain procedure codes, including ultrasound guidance used with needle placement. As a result of this billing scheme, the Defendants sometimes billed 15 to 30 identical ultrasound guidance claims for a single patient office visit.
The United States’ Second Amended Complaint separately alleged that Crumb knowingly falsified patient diagnoses in order to ensure payment by the federal health care programs. Because those programs do not cover Botox for pain management, Crumb allegedly used diagnoses of uncommon or rare neurological movement disorders for the sole purpose of obtaining reimbursement for the administered Botox injections. The United States further alleged that Crumb ordered inflated dosages of Botox medications paid by the Alabama Medicaid Agency that were not medically necessary and were not used on the patients for whom the medication was prescribed.
The investigation and litigation were conducted by the Office of Inspector General, Department of Health and Human Services (OIG-HHS), and the U.S. Attorney’s Office. Assistant United States Attorneys Deidre Colson and Daryl Atchison handled the case on behalf of the United States. As part of the settlement, Crumb entered into a Corporate Integrity Agreement with OIG-HHS, which obligates Crumb to undertake substantial internal compliance reforms and to submit his federal health care program claims to independent review for the next three years.
The FCA claims settled are allegations only, and there has been no determination of liability.