United States Settles False Claims Act Allegations Against Jacksonville-Based Fertility Clinic
Jacksonville, FL - The United States has settled allegations that a Jacksonville-based fertility practice knowingly billed the government for services that were “up-coded,” or billed at a rate higher than medically necessary, and billed for certain claims when the physician-owner was out of the country. The allegations resolved included liability under the False Claims Act (FCA).
The government announced today that it has reached a settlement with the Jacksonville Center for Reproductive Medicine (Center), and the physician who owned the practice – Dr. Michael Fox. In reaching this settlement, the parties resolved allegations that, from January 1, 2009, until February 2013, Dr. Fox operated a fertility practice that billed for services at a higher rate of reimbursement than appropriate. At issue, in particular, was the misuse of “incident to” billing provisions. In general, the government allows medical professionals to bill for the services of physician assistants and nurse practitioners as fully compensable claims when those services are “incident to” a physician’s course of treatment. In this case, the government alleged that the Center routinely misused the “incident to” provisions when it billed for work performed by a physician assistant or nurse practitioner. In many instances, it appeared that physician involvement was minimal such that the “incident to” provision would not be applicable. The government agreed to accept $98,838.98 to resolve these allegations.
“TRICARE and other federal health care programs are dependent upon healthcare providers honestly reporting the work that they do,” said A. Lee Bentley, III, U.S. Attorney for the Middle District of Florida. “Claiming reimbursement for treatments not provided, or at higher rates than authorized by regulation, defrauds taxpayers and depletes limited funds available to provide medical care to deserving patients. By bringing False Claims Act cases such as this, we recover funds stolen from the government and deter others from attempting similar schemes.”
Today’s settlement involved false claims submitted to the TRICARE Program. This case was developed by proactively mining healthcare reimbursement data. In mining through this data, the Center was identified as a top biller of fertility related treatments. In addition, through this data mining, government investigators were able to determine that the Center had billed for services allegedly rendered by Dr. Fox – the owner of the practice – even when he was out of the country.
This settlement illustrates the government’s emphasis on combating health care fraud and marks another achievement for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced in May 2009 by the Departments of Justice and Health and Human Services. The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation. One of the most powerful tools in this effort is the False Claims Act. Since January 2009, the Justice Department has recovered a total of more than $19 billion through False Claims Act cases, with more than $13.4 billion of that amount recovered in cases involving fraud against federal health care programs.
"This settlement highlights the commitment of the Defense Criminal Investigative Service (DCIS) and its law enforcement partners to protect the integrity of the Department of Defense (DoD) health care program," said Special Agent in Charge John F. Khin, Southeast Field Office. “DCIS will actively analyze, inquire, and challenge health care providers that overcharge the DoD, mistakenly or otherwise. We do this to preserve American taxpayer dollars intended to care for our Warfighters, their family members, and military retirees."
This case was investigated by Defense Criminal Investigative Services, Defense Health Agency Program Integrity Office, and Assistant United States Attorney Jason Mehta.
The claims resolved by this settlement are allegations only, and there has been no determination of liability.