Qui Tam Action Results in $4.1 Million Settlement with Oncology Provider

A multi-million dollar settlement was previously reached with one of the country’s largest and busiest oncology practices for qui tam claims that were filed under the federal False Claims Act. Georgia Cancer Specialists (GCS), which is based in Atlanta, has agreed to pay the government $4.1 million to resolve allegations it defrauded Medicare of millions of dollars.

Details of the Medicare Fraud

According to the government’s complaint, Georgia Cancer Specialists was able to fraudulently obtain payments from Medicare by participating in an overbilling scheme. The allegations specifically focus on the manner in which GCS continually billed Medicare for evaluation and management (E&M) services on the same day the related procedure was performed. Under Medicare’s rules and regulations, healthcare providers are not normally allowed to bill for E&M services that are provided on the same day as the medical procedure itself. As with most guidelines, however, there are some exceptions to the rule.

Only in specific circumstances can providers avoid the E&M issue. This is done by submitting claims marked with modifier 25, which tells Medicare to pay for both the procedure and the E&M service. The U.S. Attorney’s Office alleged that GCS used modifier 25 in multiple claims that did not qualify for its use, leading to Medicare fraud.

What are E&M Services?

Evaluation and Management services is a term that describes a physician’s office visit set up specifically to evaluate a medical condition and determine the best course of action for managing that condition. When it comes to billing for oncology services, an E&M service is routinely bundled with other services provided on the same day, including treatments like chemotherapy, but is not eligible for billing under Medicare unless it can be identified as a “significant, separately identifiable service.”  If it is determined to be an eligible separate service, then the modifier 25 is used, identifying it as billable under Medicare’s guidelines.

When a healthcare provider adds the modifier 25 billing code and submits the claim to Medicare, it is officially certifying that the medical services qualify for one of the exceptions that permit billing for E&M and the related procedure on the same day. By supplying false certifications to a government entity, a medical provider violates the False Claims Act and commits Medicare fraud.

The False Claims Act Case Against GCS

Healthcare providers use specific codes to bill Medicare for particular services they perform. When bogus codes are used to submit claims to Medicare, it is considered a fraudulent and illegal act. “Upcoding” is a term that describes the improper use of a billing code for a medical procedure or diagnosis that results in a higher payment to the medical provider than what is warranted by the real procedure or diagnosis.

In the False Claims Act case filed against GCS, the government alleged the oncology provider submitted multiple claims in which modifier 25 was improperly used, causing false and fraudulent billing claims to be submitted for payment to Medicare.

Due to the complexity of the Medicare coding system and the electronic review of claim submissions, it is nearly impossible to examine each and every code that is billed. The lack of monitoring when it comes to these electronically submitted claims makes the Medicare billing system a target for abuse. As with other forms of government fraud, the practice of Medicare fraud via upcoding is usually revealed by a whistleblower with first-hand knowledge or suspicion of the fraudulent activity.

As a result of widespread abuse related to the modifier 25 billing code, the Department of Health and Human Services, Office of Inspector General has targeted its use. A focus on the abuse of the modifier 25 billing code was initiated due to a massive number of healthcare providers improperly using the modifier, which resulted in millions of dollars of fraudulent payments to Medicare providers.

Under the False Claims Act, a qui tam whistleblower may come forward and report information of fraudulent activity. After consulting with an experienced qui tam attorney, whistleblowers can opt to sue on behalf of the federal government and assist in the recovery of damages. After reviewing complaints filed under the False Claims Act, the government may choose to intervene in the qui tam action. However, whistleblowers may, with the guidance of a trusted qui tam lawyer, successfully pursue a False Claims Act lawsuit regardless of whether the government intervenes.

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