United States Attorney's Office District of Connecticut
Press Release

PEDIATRIC PRACTICE PAYS $74,644 TO SETTLE ALLEGATIONS UNDER THE FALSE CLAIMS ACT

Nora R. Dannehy, United States Attorney for the District of Connecticut, today announced that FAIRFIELD COUNTY HEALTHCARE ASSOCIATES, P.C., doing business as Pediatric Healthcare Associates (PHA), a pediatric medical practice with a business address at 15 Corporate Drive, Trumbull, Connecticut, and with offices in Bridgeport, Fairfield, Shelton, Southport, Stratford, and Trumbull, has entered into a civil settlement agreement with the Government in which it will pay $74,644 to resolve allegations that it violated the False Claims Act.

U.S. Attorney Dannehy explained that the allegations against PHA involved improper billing of a “special services” code.  When services such as office visits are provided on days when the office is normally closed or after a provider’s usual office hours, a provider is permitted to bill an add-on code and receive an extra payment, in addition to the payment for the underlying service.  At various times between 2004 and 2008, the so-called “after hours” billing code (CPT code 99050) was defined as services requested after a medical provider’s “posted office hours,” and/or services provided “at times other than regularly scheduled office hours, or days when the office is normally closed (e.g. holidays, Saturday or Sunday).”

In 2006, the American Medical Association provided the following guidance as to when this add-on code could be properly billed:  “A patient develops severe ear pain that is unresponsive to home treatment.  Late Monday evening after the office is closed, the physician agrees by telephone to meet the patient in the office to provide treatment.  CPT code 99050 is reported in addition to the basic service.”  The American Academy of Pediatrics also issued guidance on this and other add-on codes in 2004: “[I]f routine office hours are advertised as 7:00 a.m. to 11:00 p.m. the after-hours code (99050) would not apply until after 11:00 p.m. . . . In addition, the AMA further clarifies the use of these codes by indicating they cannot be used when the physician and staff ‘plan’ to be at the office ready and available to address patients who may require care, albeit previously unscheduled.”

The Government alleges that PHA routinely billed for the special add-on code when the practice was not closed, but instead was open for business and regularly scheduling patients.  During part of the time period in question, PHA had hours posted on its web site indicating that   its offices were open in the evenings until 9 p.m. on most weekdays, and that the practice was open and had regular hours on Saturdays and Sundays.  Although PHA was regularly open during these time periods, it routinely billed Medicaid for the add-on code and received additional payments, above and beyond the usual payments for the services in question.

To resolve its liability under the False Claims Act, PHA will pay double damages, in the amount of $74,644, in order to reimburse the Medicaid program for conduct occurring between January 1, 2004 and March 31, 2009.  The False Claims Act provides for treble damages and penalties of $5,500 to $11,000 per false claim submitted to the Government.

“The U.S. Attorney’s Office is committed to vigorously pursuing those who defraud the Medicaid program,” U.S. Attorney Dannehy stated.  “Health care providers who improperly charge for care will be held accountable.”

In entering into the civil settlement agreement, PHA did not admit liability.

This case was investigated by the Federal Bureau of Investigation and the Office of Inspector General for the Department of Health and Human Services and was prosecuted by Assistant United States Attorney Richard M. Molot, along with Auditor Kevin A. Saunders.

People who suspect health care fraud are encouraged to report it by calling 1-800-HHS-TIPS or the Health Care Fraud Task Force at (203) 785-9270.

CONTACT:

U.S. ATTORNEY'S OFFICE
Tom Carson
(203) 821-3722
thomas.carson@usdoj.gov