In a recent settlement between the Department of Justice and a Florida cosmetic surgeon, the latter has agreed to pay $4 million to settle expansive allegations of Medicare fraud.[1. Department of Justice Press Release, “Florida Physician Agrees to Pay $4 Million and To Accept a 5-Year Exclusion From Medicare to Resolve False Claims Act Allegations.”June17, 2015. http://www.justice.gov/usao-sdfl/pr/florida-physician-agrees-pay-4-million-and-accept-5-year-exclusion-medicare-resolve-0] The case was originally initiated by two former employees of the physician, a technician and another surgeon – both of whom will share a $920,000 qui tam reward. The lawsuit stems from the surgeon’s alleged overuse of the “Mohs” surgical procedure, which is only covered by Medicare and Medicaid in limited circumstances.
Despite denying any liability in the matter, the physician and his cosmetic surgery practice are prohibited from participating in Medicare and Medicaid for the next five years.
Details of the allegations against the Florida doctor
Located in South Florida, the Vero Beach physician saw a number of patients suffering from the onset of skin cancer and cancerous lesions caused by sun damage. Moreover, the physician had an active referral stream from dermatologists in the area who opted to send patients to the surgical center for a procedure known as Mohs surgery.
Mohs surgery is defined by the Center for Medicare and Medicaid Services as “a precise, tissue-sparing, microscopically controlled surgical technique used to treat selected skin cancers. It is an approach that aims to achieve the highest possible cure rates, and minimize wound size and consequent distortions at critical sites such as the eyes, ears, nose, and lips.” Medicare will only cover the costs of Mohs surgery if the surgeon performing the procedure acts as both a pathologist and surgeon, and Medicare will not cover a bifurcated approach wherein a separate doctor analyzes diagnostic images or biopsies.
Here, the two relators allege that the doctor accepted patients for Mohs surgery and billed Medicare for the procedure despite never actually performing diagnostic testing on the patients’ affected areas.[2. “Vero Beach surgeon pays $4M to resolve false Medicare billings.” June 22, 2015. http://www.wptv.com/news/region-indian-river-county/vero-beach/vero-beach-surgeon-pays-4m-to-resolve-false-medicare-billings] In addition, the allegations assert that the doctor actually diagnosed patients with skin cancer and performed Mohs surgery procedures where the presence of skin cancer was either never confirmed or was known to not exist at all.
The Mohs surgery technique generally requires a two-step process wherein the skin lesions are removed in layers. In an additional set of allegations, the doctor is accused of actually prolonging the process to three, four, or more steps, which was described by experts to be far outside the “norm” when treating patients for skin cancer.
The U.S. Attorney’s Office for the Southern District of Florida said in a statement, “The settlement announced today demonstrates this office’s commitment to aggressively pursue physicians who put their own financial self-interest over a duty to their patients and thereby raise the cost of healthcare for all of us as patients and taxpayers….We will not allow physicians to put patients at risk by performing unnecessary procedures, or permit them to make up phantom claims to increase their reimbursements from Medicare.”
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Department of Justice Press Release, “Florida Physician Agrees to Pay $4 Million and To Accept a 5-Year Exclusion From Medicare to Resolve False Claims Act Allegations.”June17, 2015. http://www.justice.gov/usao-sdfl/pr/florida-physician-agrees-pay-4-million-and-accept-5-year-exclusion-medicare-resolve-0