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We are attorneys that investigate False Claims Act cases nationwide, including in the state of New Jersey for Medicare fraud, tax fraud, contractor fraud and more against a range of employers including healthcare providers, medical device companies, defense contractors, and pharmaceutical companies. We stand ready to provide a free case evaluation to you; please call us today.

FALSE CLAIMS ACT CASES IN THE NEWS

As False Claims Act attorneys, and especially attorneys who represent clients that have the courage to blow the whistle on fraud against the federal government, we are pleased to see that the United States Attorney’s Office for the Northern District of Georgia announced that it has reached a settlement with Georgia Cancer Specialists I PC, which agreed to pay $4.1 million to settle claims that it violated the False Claims Act by billing Medicare for evaluation and management services that were not permitted by Medicare rules. Georgia Cancer Specialists is one of the largest private oncology practices in the country with 27 offices located throughout the Atlanta metro area.

We have already posted once on this settlement, which you can read HERE.

The civil settlement resolves the United States’ investigation into Georgia Cancer Specialists’ practices relating to billing for evaluation and management (E&M) services on the same day as a related procedure. Generally, providers are not permitted to bill both E&M services and a related procedure on the same day under the Medicare program’s regulations. In specific circumstances, providers can avoid this prohibition by submitting their claims marked with modifier 25, which tells Medicare to pay both the procedure and the E&M service. Here, the U.S. Attorney’s Office alleged that Georgia Cancer Specialists applied modifier 25 to claims that did not qualify for its use, leading to overpayments by Medicare.

MODIFIER 25

Physicians cannot improperly use Modifier 25. Modifier 25 is for significant, separately identifiable evaluation and management (E/M) service by the same physician* on the day of a procedure. By “SAME PHYSICIAN” Medicare regulations explain that “Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician.” The same physician concept also applies when the exact same physician performs services.

E/M Services are those services provided by physicians and non-physician practitioners to evaluate patients and manage their care. The code is chosen based on where the service is performed, the extent of history taken, the extent of the examination and the level of medical decision making.

In other words, two separate physicians in the same group cannot use Modifier 25 when treating the patient on the same day. It is therefore improper under Medicare for a physician other than the physician* performing the procedure to apply in a Modifier 25 situation. Likewise, if documentation shows the amount of work performed is consistent with that normally performed with the procedure, Modifier 25 is not proper.

Modifier 25 indicates that on the day of a procedure, the patient’s condition required a significant, separately identifiable E/M service, above and beyond the usual pre and post-operative care associated with the procedure or service performed.

Occasionally two physicians in the same group with the same specialty (but different subspecialties) see the patient on the same day. Medicare does not recognize subspecialties on front-end claims processing. The physician may use Modifier 25 if the documentation meets the definition above. Please submit the documentation when requesting a redetermination.

The end result: Medical providers are utilizing Modifier 25 without proper facts to support the use of same. In other words, you may have a situation where Physician A treats a patient for procedure X and on the same day of treatment, Physician B (a partner of Physician A) performs E/M. That would likely be an improper use of Modifier 25. Similarly, if Physician A performed both procedure X and E/M, Physician A would need to show clear facts that justify the use of the procedures. Otherwise, E/M would not be properly billed under Modifier 25. It would make sense that Physician A should be doing some E/M anyway as part of Procedure X.

Does this sound familiar? We would be honored to help you. You may have some additional questions about False Claims Act claims. If you would like more information on False Claims Act cases, please continue reading as we will accept nationwide case evaluations to try and help you pursue justice.

THE SCOPE OF FRAUD

Amazingly, some estimates have suggested that approximately 10% of the entire annual United States budget is lost to companies or individuals who are defrauding the government. The United States Federal budget for 2010 was $3.456 billion, meaning around $345.6 million was wrongfully wasted on fraud.

The entities defrauding the government do so in a variety of ways: Medicare or Medicaid fraud whereby they bill the government for services which they never provided or overbill for services that were provided; SEC Trading; Tax Fraud; TARP Fraud; Military/Defense contract fraud; Pharmaceutical Manufacturing;contract fraud involving any number of large government spending programs; or other types public benefit fraud.

HELPING THE PUBLIC.

As a whistleblower attorney, we are interested in speaking with persons willing to make known the truth about company practices and are willing to file a qui tam or whistleblower action. One area in particular we are interested in discussing are lawsuits involving medical device companies where the company is alleged to have overcharged, engaged in kickback programs, and the like. We will nevertheless investigate claims in a variety of areas.

Workers and persons all across the country witness actions at their work that may be unlawful or even corrupt. Unfortunately, some employees and workers feel that they will be fired, terminated, harrassed or punished if they report an unlawful or corrupt action. These reporters, however, are protected by the law as a Whistleblower and can receive compensation because of the False Claims Act or the Medicaid False Claims Act. If you have reported actions that may be fraudulent, then you should talk to a Whistleblower or qui tam lawyer about your facts.

Whistleblowers help the government to get back billions of dollars each year with the help of the False Claims Act. In fact, fraudulent Medicaid claims are also caught by whistleblowers having the Medicaid False Claims Act on their side. If you report a false claim or fraudulent action to the government, then the government will give you, the whistleblower, a part of the money that gets recovered. This is because of qui tam requirements. Qui Tam means that a person files a lawsuit for the king and also for him or herself. The phrase is qui tam pro domino rege quam pro se ipso in hac parte sequitur, or, “he who sues for the king as well for himself.”

These requirements and lawsuits were made popular during the Civil War when many people were getting away with fraudulent actions against the government. In 1986, the False Claims Act was amended to raise the total compensation given to people who reported fraudulent actions, or whistleblowers. If a whistleblower works with a lawyer then it may be possible for them to get three times the amount the government would get in damages and also get additional compensation for general fines.

TYPES OF CASES

The most common situations that could form the basis of a Qui Tam action include:

• Submitting a false or fraudulent record, bill or statement to the government in order to fraudulently obtain money such as reporting a medical service that was never performed for Medicare or Medicad;
• Conspiring with a third party to submit or present have a false or fraudulent claim to the government;
• Withholding property of the government with the intent to defraud or conceal the property from the government;
• Fraudulently buying property of the government from someone not authorized to sell that property; and
• Making a false statement to fraudulently avoid paying money to the government or to avoid delivering property to the government.

FOR HELP, PLEASE CONTACT US.

We help whistleblowers on a contingency basis, meaning there is no fee charged for our work unless there is a recovery. We also front any and all expenses. No matter where you are located — we will represent you. We will come to you, you will not have to come to us.

Attorneys in our firm and attorneys that we work with on Whistleblower, Qui Tam, False Claims Act cases have represented a host of persons making claims, for violations of federal tax law, Medicare law and more.

For more information, please contact our team of whitsleblower and qui tam attorneys today.

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