In separate statements issued on December 7, 2016, the U.S. Attorney’s Office for the Middle District of Florida and the U.S. Attorney’s Office for the Southern District of Florida announced the settlement of two separate False Claims Act (FCA) matters, with the combined settlements totaling nearly $15 million.
In the Middle District, U.S. Attorney A. Lee Bentley, III, announced that Southeast Orthopedic Specialists (SOS) had agreed to pay $4.488 million to resolve allegations that the medical group had violated the FCA by seeking reimbursement for a number of services that were not medically necessary and reasonable. The questionable activities included the utilization of certain billing codes that did not accurately reflect the services provided, the inappropriate use of billing modifiers that garnered additional payments from federal health care programs, and the scheduling of patient follow-up appointments 12-14 weeks after operative visits—thus enabling SOS to dodge Medicare’s 90-day diagnosis-related group charge and receive a larger reimbursement.
“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.”
Meanwhile, U.S. Attorney for the Southern District of Florida Wilfredo A. Ferrer and a team of investigators from the U.S. Department of Human Services, the Defense Criminal Investigative Service and the Office of Personnel Management collectively announced a $12 million settlement with South Miami Hospital to settle allegations that it had violated the FCA by submitting false claims to multiple federal health care programs for medically unnecessary heart procedures performed by Dr. John R. Dylewski. The suit was initially brought under the qui tam provisions of the FCA by two whistleblowers, Drs. James A Burkes and James D. Davenport. The two physicians, a vascular surgeon and cardiologist, respectively, claimed to have personal knowledge of Dylewski and the hospital performing a number of unnecessary cardiac procedures, including echocardiograms, electrophysiology studies, and other treatments of arrhythmia by ablation, cryoablation, or implantation of an electronic device, for the sole purpose of increasing reimbursements from Medicare and other federally-funded healthcare programs.
U.S. Attorney Ferrer remarked, “This settlement shows our continued resolve to pursue institutional providers who turn a blind eye to the systematic overutilization of medical procedures and inflated billing practices resulting in significantly increased costs to the federal government.”
In both cases, the U.S. attorneys stressed the commitment of the government to protect the integrity of federally funded health care programs. These settlements also serve to further demonstrate the government’s commitment to combatting healthcare fraud. Since May 2009, with the creation of the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, the Justice Department has recovered more than $31.6 billion through False Claims Act cases, with approximately $19.2 billion of that amount derived from healthcare fraud.