By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health
On December 7, 2016, Southeast Orthopedic Specialists (SOS), located in Jacksonville, Florida, agreed to pay $4,488 million to settle allegations that it violated the False Claims
) by allegedly billing federal health
care programs for millions of dollars in unnecessary services.
Protection of Federal Health Care Programs.
An announcement was made by U.S. Attorney
A. Lee Bentley III of the Middle District of Florida. In the statement he said: "The United States Attorney
's Office is committed to taking the steps necessary to protect Medicare
and other federal health
care programs from fraud. When health
care practitioners submit fraudulent claims
for reimbursement, we will hold them accountable."
The U.S. Department of Justice (DOJ) said that SOS submitted claims for payment declaring that a physician had been present during the patient visits, even if there was not really one there. The medical center also billed Medicare
for ultrasound-guided injections that were unnecessary, it was alleged.SOS Modified Its Billing.
According to the allegations, a billing modifier was used by SOS that showed separate evaluations and management (E&M) services were performed, while in reality, those services were not separate. This resulted in higher payments by Medicare
. SOS also used a modifier that showed two procedures were conducted, when the procedures should have been billed together as one. This is known as "unbundling."
According to the allegations, sometimes a third modifier was used by SOS to falsely surpass the Medicare
cap on physical therapy, even though there was no medical need for it.
The prosecutors stated that SOS also scheduled for patient follow-ups 12 to 14 weeks after the operative visits. This allowed SOS to avoid Medicare
's 90-day diagnosis-related group charge. Because of this, SOS was able to receive a greater reimbursements. The Government Is More Aggressively Fighting Health Care Fraud.
settlement reveals the emphasis the government is putting on fighting health
care fraud. It marks yet another achievement for the Health
Care Fraud Prevention and Enforcement Action Team (HEAT) initiative. FCA
recoveries reached an all time high during the previous year and the government is expected to continue to pursue these claims.
Special Agent in Charge Shimon Richmond is reported to have stated, "The Department of Health
and Human Services, Office of Inspector General
will relentlessly seek out those who defraud the Medicare
program. Obtaining tax dollars which Medicare
providers are not entitled to impact our entire healthcare system and the OIG
will hold health
care providers accountable who misrepresent services to boost profits."
Contact Experienced Health Law Attorneys.
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, nurses and other health
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, regulatory matters, licensing issues, litigation
, inspections and audits involving the DEA
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) and other law enforcement agencies. Its attorneys include those who are board certified by The Florida Bar in Health
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"United States Settles False Claims
Act Allegations Against Orthopedic Surgery Practice For $4,488,000." United States Department of Justice. (December 7, 2016). Web.
Pelican, Garret. "Feds Settle Health
Care Fraud Case For $4.5 Million." The Florida Times. (December 7, 2016). Web.
Kass, Dani. "Fla. Orthopedic Center Pays $4.5M To End FCA
Claims." Law360. (December 7, 2016). Web.
About the Author:
George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health
Law is an attorney
with The Health
Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health
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