On Wednesday, United States Attorney A. Lee Bentley, III announced 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 United States contends that it has certain civil claims against SOS arising from SOS billing federal healthcare programs for services that were not medically necessary and reasonable. Specifically, the United States contends that SOS sought reimbursement for millions of dollars of healthcare claims that were questionable. The United States alleges that these questionable bills include:
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.”
“The Department of Health and Human Services, Office of Inspector General will relentlessly seek out those who defraud the Medicare program,” said Special Agent in Charge Shimon Richmond. “Obtaining tax dollars which Medicare providers are not entitled to impacts our entire healthcare system and the OIG will hold health care providers accountable who misrepresent services to boost profits.”
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. The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation. One of the most powerful tools in this effort is the False Claims Act. Since January 2009, the Justice Department has recovered a total of more than $31.6 billion through False Claims Act cases, with more than $19.2 billion of that amount recovered in cases involving fraud against federal health care programs.
This matter was investigated by the U.S. Department of Health and Human Services. It was prosecuted by Assistant United States Attorney Jason Mehta.
The claims resolved by this settlement are allegations only, and there has been no determination of liability.
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