Wednesday, March 6, 2013
Health Care Fraud Settlement Reached in State and Federal InvestigationThe U.S. Attorney for the Southern District of Texas issued the following news release on March 5, 2013:
HOUSTON – Children’s Physician Services of South Texas (CPSST) and Radiology Associates have agreed to pay to settle claims they violated the False Claims Act and the Texas Medicaid Fraud Prevention Act between 2002 and 2007, United States Attorney Kenneth Magidson announced today. CPSST, a part of the Driscoll Health System, has agreed to pay $1.5 million, while Radiology Associates, an independent physician group serving the Driscoll Health System, will pay $800,000 to settle claims they billed and received payment twice for the professional reading and interpretation of genetic ultrasounds.
“Improper double billing by health care providers defrauds the government funded health care programs, adds to the government’s deficit and, most importantly, reduces the funds available to meet the patients’ medical needs,” said Magidson. “In addition to yielding a substantial recovery for taxpayers, this settlement should serve notice to health care providers that taxpayers will not tolerate, much less accept, paying twice for services rendered to them.”
The settlement announced today involved allegations that CPSST billed and received payment for Radiology Associates’ professional services and, without disclosing the payments, directed Radiology Associates to bill and receive payment for the same professional services.
There are two components for each ultrasound, a technical component and a professional component. The technical component refers to the actual taking of the ultrasound by a technician and the professional component refers to the reading and interpretation of the ultrasound images by a physician, usually a radiologist. CPSST made arrangements to have Radiology Associates read and interpret the ultrasounds taken at CPSST. From Jan. 1, 2002, to June 1, 2007, Radiology Associates read and interpreted several thousand ultrasounds for CPSST. The understanding between the two providers was that CPSST would bill and receive payment solely for the technical component and Radiology Associates would bill and receive payment solely for the professional component. In reality, CPSST billed and received payment for both the technical and professional components without informing or disclosing this fact to Radiology Associates. Upon discovery of this fact, Radiology Associates informed CPSST about the double billing for the professional component, but CPSST denied billing for the professional component except for a few accidental and isolated occasions. Instead, CPSST instructed and directed Radiology Associates to continue to bill for the professional component and reaffirmed that CPSST would only bill for the technical component. Despite additional evidence of double billing, Radiology Associates ignored the evidence, accepted CPSST’s misrepresentations without question and continued to bill and receive payment for the professional component.
Government funded health care programs such as Medicare, Medicaid, TRICARE and the Federal Employees Health Benefits program agree to pay enrolled health care providers once for the technical and professional components of each ultrasound performed on a patient covered by theses health care programs. Health care providers enrolled and servicing patients covered by these government funded health care programs are prohibited from billing and receiving payment twice for the ultrasound’s technical or professional component.
The settlement resolves allegations made against Radiology Associates, Children’s Physician Services of South Texas, Center for Genetic Services, and Raymond C. Lewandowski Jr. M.D. in a qui tam or whistleblower lawsuit filed in 2008 by a former revenue manager and coding compliance officer with Radiology Associates. Under the False Claims Act, private citizens can bring suit on behalf of the government and share in any amounts that are obtained through that legal action. In this case, the share will be between 15 - 25% of the proceeds of the overall settlement.
The investigation was conducted by the United States Department of Health and Human Services - Office of Inspector General and the Texas Attorney General's Medicaid Fraud Control Unit and Civil Medicaid Fraud Division. Assistant United States Attorney Jose Vela Jr., Assistant Texas Attorney General Christen Nedwick and MFCU Investigative Auditor Clint Lawhon led the investigation.