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Court: United States District Court for the Eastern District of Pennsylvania (Philadelphia County)
Plaintiff's Attorney: United States Attorney’s Office in Philadelphia
Description: Philadelphia, Pennsylvania criminal defense lawyer represented Defendants accused of submitting false claims by misrepresenting the severity of illness and services rendered to increase reimbursement from the Medicare Part C (Medicare Advantage) and Part B programs.
CPS, a primary care physician practice located in Philadelphia, treated patients under the Medicare Advantage program and the Medicare Part B (Medical Insurance) program. The government alleges that CPS caused the submission of false claims for payment to Part C from January 1, 2015, to December 31, 2018, arising from CPS submitting unsupported diagnosis codes, resulting in increased reimbursement to Part C health insurance companies. Specifically, CPS submitted morbid obesity diagnosis codes to Part C where the diagnoses lacked medical support in that patients had a body mass index under 35. The government contends that the diagnosis of morbid obesity in this situation is inappropriate. Further, the government alleges that CPS’s submission of chronic obstructive pulmonary disease (“COPD”) diagnoses were not medically supported or supported by appropriate medical documentation in many instances. As a result of these unsupported diagnoses, CPS substantially increased Part C reimbursement from the Centers for Medicare & Medicaid Services (“CMS”).
The government also alleges that CPS caused the submission of inappropriate claims to the Medicare Part B program that were not supported by medical documentation from January 1, 2015, to December 31, 2018, in order to maximize its reimbursement. Specifically, the government contends that CPS improperly billed Evaluation and Management visits using Current Procedural Terminology Code 99214 without the requisite level and complex medical decision making that this code requires. Further, CPS inappropriately billed physician assistant services “incident to” the professional services of a physician including occasions when the physician was out of the country. Finally, CPS also submitted unsupported billing to CMS for smoking cessation counseling, pulmonary function tests, and unsupported claims for vaccine administration.
“Almost half of Medicare beneficiaries are now enrolled in Medicare Advantage plans. Investigation of credible allegations of fraud impacting it is more important than ever,” said U.S. Attorney Romero. “The Medicare Advantage Program relies on accurate information about its enrollees’ health status, such as whether they really have morbid obesity or COPD. It is imperative that enrollees receive appropriate treatment and that participating providers and health plans receive proper compensation for the services they actually provide. We will hold accountable those who report unsupported diagnoses to inflate Medicare Advantage payment.”
“Today’s settlement shows our attention to and commitment in investigating all potential allegations of fraud against the Medicare Part C Programs, no matter the size of the physician practice, or the complexity of the scheme,” said Maureen R. Dixon, Special Agent in Charge for the U.S. Department of Health and Human Services, Office of the Inspector General. “We will continue to partner with the United States Attorney’s Office to evaluate allegations brought under the False Claims Act to ensure the integrity of Medicare programs.”
This settlement resolved a lawsuit filed under the False Claims Act in the U.S. District Court for the Eastern District of Pennsylvania by former CPS employees captioned United States ex rel. Michael Helzner, D.O., et al. v. Complete Physician Services, LTD, at al., No. 16-cv-5401 (E.D. Pa.). Under the qui tam or whistleblower provisions of the False Claims Act, lawsuits like this one may be brought on behalf of the United States and the relators share in any recovery by the government. The relators were represented in this case by John M. Hanamirian of the Hanamirian Law Firm. “We thank the relators and the relators’ counsel for their contributions. Detecting fraud is much easier when we have the cooperation of whistleblowers like the ones in this case,” said Romero.
This matter was investigated by the U.S. Attorney’s Office for the Eastern District of Pennsylvania, in conjunction with the U.S. Department of Health and Human Services Office of Inspector General. The investigation and settlement were handled by Assistant U.S. Attorney Deborah W. Frey, Civil Division Chief Gregory B. David, and Auditor George Niedzwicki.
The claims resolved by this settlement are allegations only and there has been no determination of liability.
Outcome: Defendants' agree to pay $1.5 million to resolve the claims made against them.