Category: Compliance

Adam B. Smith, M.D., also known as “Adam Bryant,” has been sued by the United States for two counts of violating the False Claims Act, 31 U.S.C. §3729 et seq. The claims are contained in a Civil Complaint filed by both the United States and the State of Iowa on May 9, 2023, in the United States District Court for the Northern District of Iowa.

The complaint alleges that from approximately August 2014 to August 2019, Smith, a plastic surgeon practicing in Sioux City during that time, submitted or caused to be submitted false claims for healthcare services to government payors, including Medicare. The complaint alleges Smith did so by: (1) billing government payors for services he claimed were medically necessary surgical procedures, but that were in actuality medically unnecessary cosmetic surgeries, which are not payable by government payors; (2) billing for services in excess of those actually rendered (“upcoding”) to increase reimbursement, or even billing for surgical procedures he didn’t perform at all; and (3) overstating the complexity of office visits with patients in order to obtain greater reimbursement from government payors.

https://www.justice.gov/usao-ndia/pr/united-states-files-complaint-alleging-iowa-surgeon-caused-submission-false-claims

May 17, 2023

RALEIGH) Attorney General Josh Stein today reached a $150,000 settlement with Compassionate Counseling Services in Rockingham to resolve allegations that the company submitted false claims to the North Carolina Medicaid program. The settlement funds will be returned to the program.

“Health care providers that receive Medicaid resources need to use those resources properly,” said Attorney General Josh Stein. “When providers fail to responsibly steward taxpayer dollars, my office will hold them accountable. I’m grateful to the U.S. Attorney Hairston and her office for their continued partnership to protect health care resources.”

https://ncdoj.gov/attorney-general-josh-stein-reaches-150000-medicaid-fraud-settlement-with-rockingham-health-care-provider/

 New York Attorney General Letitia James today announced that her office has reached a civil settlement with Dr. David B. DiMarco, M.D. and his companies D.B. DiMarco, M.D., P.C. (D.B. DiMarco) and DiMarco Vein Centers LLC (DiMarco Vein Centers), securing more than $2 million for Medicaid. The settlement resolves an investigation by the Office of the Attorney General (OAG) into illegal Medicaid billing practices for vein treatments performed by Dr. DiMarco. The OAG found that Dr. DiMarco submitted more than 1,000 claims for procedures to Medicaid without sufficient documentation to show what procedures were actually performed or why the procedures were medically necessary, resulting in overpayment of Medicaid reimbursement. As a result of the settlement announced today, DiMarco will pay $2,139,037 to Medicaid and he will also withdraw from the New York State Medicaid program.

https://ag.ny.gov/press-release/2022/attorney-general-james-secures-over-2-million-medicaid-settlement-western-new

Vanessa Roberts Avery, United States Attorney for the District of Connecticut, and Phillip Coyne, Special Agent in Charge for the U.S. Department of Health and Human Services, Office of the Inspector General, today announced that JASDEEP SIDANA, M.D. and DOCS MEDICAL GROUP, INC. (doing business as Docs Medical), DOCS MEDICAL INC., DOCS URGENT CARE LLP, LUNG DOCS OF CT, P.C., EPIC FAMILY PHYSICIANS, LLP, and CONTINUUM MEDICAL GROUP, LLC (collectively, “DOCS”), have entered into a civil settlement agreement with the federal and state governments in which they will pay a total of $4,267,950.21 to resolve allegations that they submitted false claims for payment to Medicare and the Connecticut Medicaid program for medically unnecessary allergy services, unsupervised allergy services, and services improperly billed as though provided by Sidana.  The agreement also resolves allegations that Sidana and DOCS improperly billed for certain office visits associated with COVID-19 tests.

Sidana is a physician who specializes in pulmonology and is the owner and Chief Executive Officer of DOCS, a medical practice with more than 20 facilities throughout Connecticut that offers a variety of services to its patients, including primary and urgent care, allergy testing and treatment, and COVID testing.

Medicare and Connecticut Medicaid pay only for services or items that are medically necessary.  Some services also have supervision requirements, allergy tests and the preparation of allergy immunotherapy must be directly supervised by a physician.  Direct supervision requires the supervising physician to be present in the same office suite, and immediately available to render assistance if needed.

https://www.justice.gov/usao-ct/pr/connecticut-physician-and-urgent-care-practice-pay-over-42-million-settle-false-claims

What OIG allegedly found:

With respect to the 10 high-risk groups covered by our audit, most of the selected diagnosis codes that Cigna submitted to CMS for use in CMS’s risk adjustment program did not comply with Federal requirements. For 195 of the 279 sampled enrollee-years, the medical records that Cigna provided did not support the diagnosis codes and resulted in $509,194 in overpayments.

https://oig.hhs.gov/oas/reports/region7/71901193RIB.pdf

HARRISBURG – The United States Attorney’s Office for the Middle District of Pennsylvania announced that Dr. Musaddiq Nazeeri, of Lebanon, Pennsylvania, has agreed to pay the United States $86,506.30 to resolve civil liability for alleged violations of the False Claims Act.

According to the United States Attorney Gerard M. Karam, between February 10, 2021 and January 21, 2022, Dr. Nazeeri billed Medicare for certain services that were not supported by the medical record. During the above timeframe, Dr. Nazeeri submitted Evaluation & Management (E&M) claims when the only service rendered was the administration of the COVID-19 vaccine. It is those type claims that were not supported by the medical record.  Dr. Nazeeri cooperated with the investigation

https://www.justice.gov/usao-mdpa/pr/medical-doctor-pay-8650630-resolve-civil-liability-alleged-violations-false-claims-act

Physician Admits Upcoding of Services

SYRACUSE, NEW YORK – Ahmad M. Mehdi and his medical practice, Ahmad M. Mehdi, M.D., P.C. (“Mehdi”), agreed to pay a total of $900,000 to resolve civil claims for up-coding billings for some medical services, billing for smoking cessation counseling services that were not adequately documented, and allegedly improper prescribing of opioids, announced United States Attorney Carla B. Freedman.

Mehdi operates a general medical practice with offices in Groton and Tully, New York.  According to the settlement agreement, between January 1, 2012, and September 17, 2018, Mehdi caused false claims to be submitted to federal healthcare programs by billing for some services at a higher rate of reimbursement than it would be entitled to for the service actually provided, a scheme commonly referred to as “upcoding.” Mehdi also submitted billing to federal healthcare programs for some smoking cessation counseling services that were not sufficiently documented.  This settlement also resolves claims that Mehdi violated the Controlled Substances Act between April 1, 2018, and December 31, 2020, by prescribing opioids outside the usual course of professional practice to three patients.  Mehdi has agreed to pay $331,250 to the United States to resolve all of these claims.  Mehdi will also pay $568,750 to the State of New York pursuant to the terms of a separate agreement.

“Providers who increase their own profits by over-billing for medical care increase medical costs for all of us and drain critical funds from Medicare and other government health programs,” said U.S. Attorney Freedman.  “We will continue to hold accountable medical professionals who undermine our healthcare system by over-billing for care.”

https://www.justice.gov/usao-ndny/pr/central-new-york-doctor-settles-improper-billing-and-controlled-substance-act-claims

What OIG allegedly found:

With respect to the six high-risk groups covered by our audit, most of the selected diagnosis codes that Highmark submitted to CMS for use in CMS’s risk adjustment program did not comply with Federal requirements. For 66 of the 226 sampled enrollee-years, either the medical records validated the reviewed HCCs, or we identified another diagnosis code (on CMS’s systems) that mapped to the HCC under review. However, for the remaining 160 enrollee-years, the diagnosis codes were not supported in the medical records. These errors occurred because the policies and procedures that Highmark had to prevent, detect, and correct noncompliance with CMS’s program requirements, as mandated by Federal regulations, could be improved. As a result, the HCCs for these high-risk diagnosis codes were not validated. On the basis of our sample results, we estimated that Highmark received at least $6.2 million of net overpayments for 2015 and 2016.1

https://oig.hhs.gov/oas/reports/region3/31900001.pdf

ALBANY, NEW YORK – North Country Neurology, P.C., a physician-owned medical practice located in Watertown, New York, has agreed to pay $850,000 for what it admitted was “improper” and “reckless” billing to the federal government for medical services, announced United States Attorney Carla B. Freedman.

“The integrity of our federal health care system depends on accurate and honest billing by medical providers,” said United States Attorney Freedman.  “While North Country Neurology will pay a steep price for submitting false claims for payment to Medicare, I commend the practice and its management for accepting responsibility for its past actions and for implementing forward-looking compliance measures in response to our investigation to assure systems are in place to facilitate and promote ethical and legal conduct in the future.”

North Country Neurology employed physicians and a physician assistant who rendered care to Medicare beneficiaries.  In certain circumstances, Medicare allows practices to bill for services rendered by a non-physician practitioner (NPP), including a physician assistant, “incident to” the services that are personally rendered by a physician.  These services, even though not personally rendered by a physician, may be billed in a physician’s name if several requirements are met.  One such requirement is that a physician directly supervise the NPP rendering the services, meaning that a physician is present in the office suite and immediately available to furnish assistance and direction throughout the procedure.  Although Medicare will reimburse practices for certain procedures rendered by NPPs without a physician’s direct supervision, such services are reimbursed at a lesser rate than service rendered or directly supervised by a physician.

North Country Neurology admitted that, on 120 occasions from September 2015 through June 2019, it “submitted or caused to be submitted claims for payment to Medicare that improperly listed a physician as the rendering provider for services rendered by a physician assistant when no physician was physically present in the office and immediately available to furnish assistance and direction throughout the performance of the procedure.”  The practice further admitted that it “knew or should have known the requirements of incident-to billing and that it was improper to submit claims to Medicare in a physician’s name for services rendered by an NPP when no physician was in the office” because, among other reasons, its billing company had informed the practice’s owner of separate incident-to billing violations several years earlier.

https://www.justice.gov/usao-ndny/pr/watertown-medical-practice-pay-850000-resolve-false-claims-act-allegations

On March 2, 2022, Metroplex Pain Consultants, LLC (Metroplex) and Dr. Steven Casey (Dr. Casey), Dallas, Texas, entered into a $110,748.12 settlement agreement with OIG. The settlement agreement resolves allegations that Metroplex submitted claims for services purportedly rendered by Dr. Casey during a time period when Dr. Casey was not at his office. Additionally, OIG alleged that Metroplex and Dr. Casey submitted claims to Medicare for spinal facet joint injections, which amounts exceeded five in a rolling 12-month period. OIG’s Office of Audit Services and Office of Counsel to the Inspector General, represented by Gregory Becker, collaborated to achieve this resolution.

https://oig.hhs.gov/fraud/enforcement/metroplex-pain-consultants-and-dr-steven-casey-agreed-to-pay-110000-for-allegedly-violating-the-civil-monetary-penalties-law-by-submitting-claims-dr-casey-did-not-perform-or-directly-supervise-and-claims-for-excessive-services/