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September 17, 2015 Healthcare Fraud

Georgia Optometrist Settles Allegations of False Billing and Upcoding for $275,000

State and federal guidelines impose strict billing requirements when it comes to routine eye care. Unlike many private insurance plans, coverage under Medicare or Medicaid generally provides reimbursement for vision services, provided the optometrist engages in medically necessary procedures.

Today we’ll review a whistleblower case filed in 2014 against optometrist Jeffrey Sponseller and his practice Eye Care One. This case alleged the Georgia-based optometrist of fraudulently billing state and federal programs for the reimbursement of services that were not necessary or that the patient did not actually receive. Sponseller and Eye Care One pleaded guilty to the accusations, and recently agreed to pay $275,000 to settle the claims against them.

Allegations against Sponseller

According to the whistleblower complaint, Sponseller was engaged in the consistent and routine practice of providing vision services to nursing home patients living in and around Augusta, Georgia. Sponseller pleaded guilty to billing Medicaid, Medicare, and the Railroad Retirement Medicare program for the “lengthiest and most expensive type of eye examination” available under the billing code, despite only visiting the patient briefly or, in some cases, not at all. This resulted in significant reimbursement requests from the office, which is often a red flag for fraudulent activity.

As a result of the alleged misconduct, the Department of Justice also opened a criminal investigation against Sponseller and his practice. Sponseller pleaded guilty to over $800,000 in fraudulent billing, and was sentenced to 33 months in prison, which he is currently serving in the Edgefield Federal Correctional Institution. Sponseller remitted nearly $500,000 in restitution to the state and federal government, in addition to his $275,000 settlement with the government over the False Claims Act allegations.

Vision guidelines

Under programs like Medicare Part B, patients are usually entitled to an annual eye examination and partial coverage for corrective eyewear – including glasses and/or contact lenses. Medicare Part B also covers preventative and diagnostic eye examinations, including examinations for macular degeneration and glaucoma.

Under Medicaid coverage, which varies greatly from one state to the next, children aged 21 and younger may be eligible for glasses and corrective contact lenses. Adult patients in Georgia may also be entitled to vision coverage under limited circumstances, such as preventative care for conditions like cataracts and glaucoma.

Government response

According to United States Attorney Edward J. Tarver, “This settlement demonstrates the United States Attorney’s Office’s commitment to pursue all available remedies against those who commit healthcare fraud.  Both criminal and civil avenues will be pursued in order to protect the American taxpayers as well as our nation’s elderly citizens, who were taken advantage of in this instance.”

Contact Berger Montague today

If you are employed in the healthcare industry and are aware of possible fraud occurring, we encourage you to contact Berger Montague right away. Oftentimes, billing fraud is conspicuously covered up to avoid detection, and meeting with an experienced whistleblower attorney to discuss your information is the best way to help uncover wasteful fraud.