California Attorney General Rob Bonta announced a settlement against a Southern California doctor for submitting false claims to Medicare and Medi-Cal between the years of 2011 and 2018 for drugs, procedures, services, and tests that were never administered to patients. As part of the settlement, the doctor will pay a total of more than $9.48 million. The state of California will receive $630,099 of that sum, plus accrued interest.
The doctor is an internal medicine practitioner who owned and operated a medical clinic located in Northridge, California. The case was filed in October 2017 under the qui tam or whistleblower provisions of the California and Federal False Claims Acts. The two whistleblowers were the doctor’s former medical assistant and his former informational technology consultant. They alleged that between November 2011 and April 2018, the doctor defrauded Medi-Cal by knowingly billing for medical services, tests, and procedures which were not provided to patients.
In October 2021, the California Department of Justice’s Division of Medi-Cal Fraud and Elder Abuse (DMFEA) and the US Attorney’s Office for the Eastern District of California intervened in the qui tam lawsuit following a joint investigation into the doctor’s billing practices. During the course of the investigation, documentation from his office revealed five categories of medical services which were the focus of the fraudulent billing schemes. These included X-rays/ultrasounds, allergy tests, various skin treatments, routine medication injections, and injections of specific high-cost medications.
The doctor’s fraudulent billing practices were also the subject of an independent federal criminal investigation initiated by a healthcare fraud strike team based in the Central District of California. The investigation culminated in the doctor pleading guilty to one count of federal healthcare fraud, and on May 2, 2022, he was sentenced to a prison term of three years and five months and ordered to pay restitution in the amount of $5.4 million.
Issue:
It is illegal to submit claims for payment to Medicare or Medicaid that you know or should know are false or fraudulent. Filing false claims may result in fines of up to three times the programs’ loss plus $11,000 per claim filed. Under the civil False Claims Act, each instance of an item or a service billed to Medicare or Medicaid counts as a claim, so fines can add up quickly. Facility staff should be knowledgeable in how to report suspicious billing practices. A nonretaliatory environment for reporting suspicious billing practices is mandatory for all facilities.
Discussion Points:
- Review your policies and procedures for preventing and reporting a false claim and for conducting a Triple Check Process to verify accuracy of Medicare claims. Ensure that your policies are reviewed at least annually and updated when new information becomes available.
- Train all staff upon hire and at least annually on your compliance and ethics policies and procedures and on what can be considered a false claim. Provide training to appropriate staff on the Triple Check Process for ensuring accuracy of all Medicare Part A billing and supporting documentation before claims are submitted. Document that these trainings occurred and file the signed document in each employee’s education file.
- Periodically perform audits to ensure all staff are aware of compliance and ethics concerns and understand their responsibility to report any potential compliance and ethics violations to their supervisor, the compliance and ethics officer, or via the anonymous hotline. Audit to ensure that the Triple Check Process is being followed each month before claims are submitted to Medicare, and that any identified irregularities are corrected.
