$6.7MM Qui Tam FCA - medically unnecessary procedures? Outside Vendor Warning!

Sharing a recent DOJ settlement as a reminder outliers are even easier to spot today, and, frankly, pretty easy to spot yesterday, too.   Medical necessity audits are NOT new, but worthy of a reminder.... 

A California physician and his Kidney & Vascular Access Center have recently agreed to pay more than $6.7 million to resolve allegations that they submitted false claims for medically unnecessary procedures. This case acts as another reminder that the government is aggressively targeting providers submitting false claims and billing for unnecessary medical interventions. 

Read the press release here: https://www.justice.gov/opa/pr/vascular-practice-and-physician-agree-pay-more-673m-settle-false-claims-act-allegations

According to the Department of Justice, the physician allegedly performed excessive interventions and procedures over the course of several years. The government claimed procedures were repeatedly performed every few days or weeks, even when patients showed little clinical need or benefit.

The allegations went far beyond simply overbilling. The DOJ alleged the physician overstated the severity of stenosis, falsely documented symptoms, and recorded conservative treatment efforts that allegedly did not occur in order to justify medical necessity. In several instances, the government claimed procedures were performed on body parts that did not qualify for treatment under accepted standards of medical practice.

When patients complained about pain in one leg, the physician performed procedures on both legs. One patient allegedly received approximately 42 stents over 7 years and another reportedly underwent 16 atherectomies in 4 years.   Justified?  If the records were there to support, it is not likely we would have this settlement to discuss.  But, to be clear, the doctor at issue settled - this case was not tried.  We only have the government's allegations, not the physician's defenses.

It's important to highlight how this case started, which was by a whistleblower - who is financially motivated to bring an action - they take home a piece of the recovery. The whistleblower in this case, an analytics company, will reportedly receive nearly $1 million from the settlement proceeds.  We are lacking details on how the analytics company garnered information, BUT, BE ADVISED, ALL OUTSIDE VNEDORS WITH YOUR BILLING DATA SHOULD BE CONTRACTED THROUGH YOUR ATTORNEY, UNDER THE KOVEL PRIVILEGE, AND BOUND BY CONFIDENTIALITY!   (caps justified!)

Investigators are increasingly relying on data analytics to identify providers whose billing patterns significantly exceed those of their peers. Although repeat procedures are not improper, if you are performing high-volume interventional services, expect heightened scrutiny when treatment frequency appears unusually aggressive or when objective findings do not clearly support continued intervention.

Now is the time to audit your records, review medical necessity protocols, evaluate documentation practices, and confirm that repeat procedures are consistently supported by objective clinical findings and accepted standards of care. Waiting until a subpoena arrives is far too late.  Being able to back up medical necessity is critical.