Florida Ophthalmology Practice Agrees to Pay $615,000 to Resolve Allegations of Fraudulent Claims to Medicare and Medicaid for Cranial Ultrasounds

Pinellas Eye Care, P.A. doing business as Gulfcoast Eye Care (“Gulfcoast Eye”), an ophthalmology practice with offices in Pinellas Park, Palm Harbor, and St. Petersburg, Florida, has agreed to pay $615,000 to resolve alleged violations of the False Claims Act and an analogous Florida statute arising from its billing for trans-cranial doppler ultrasounds (“TCDs”) provided through a kickback arrangement with a third party. Gulfcoast Eye has agreed to cooperate with the Justice Department’s ongoing investigations of other participants in the alleged scheme.

The settlement resolves allegations that Gulfcoast Eye knowingly submitted, and caused the submission of, false claims to Medicare and Medicaid for medically unnecessary TCDs. Gulfcoast Eye and a third-party provider of TCD services performed TCDs on thousands of patients and billed Medicare and Medicaid hundreds of dollars per test. Before the patients received the results of the test, Gulfcoast Eye and the third-party provider identified the patients as having received a serious diagnosis — most commonly of occlusion and stenosis of their cerebral arteries — that could qualify the patient for reimbursement of a TCD by Medicare or Medicaid. However, nearly all patients who received TCDs never had occlusion and stenosis of cerebral arteries, and that diagnosis was accordingly not reflected in the patient’s medical history or in the TCD results. Gulfcoast Eye paid the third-party TCD provider based on the volume or value of tests ordered and referred the patients to the TCD provider’s preferred radiology group for the TCD’s professional component. 

The United States alleged that, as a result of this scheme, Gulfcoast Eye submitted, or caused the submission of, false claims to Medicare and Medicaid for TCDs that were medically unnecessary, that were premised on false diagnoses, and that resulted from violations of the Anti-Kickback Statute and the Stark Law. Of the $615,000 total settlement amount, $602,046 is to be paid to the United States, and $12,953 is to be paid to the State of Florida for its share of Medicaid, which is a jointly funded federal and state program.

“Patients trust their healthcare providers to administer reliable and competent care consistent with their medical needs and ethical standards,” said U.S. Attorney Gregory W. Kehoe for the Middle District of Florida. “When this relationship is exploited for personal gain or greed, the integrity of our healthcare system is compromised. We will continue working with our law enforcement partners to protect patients from potential harm and maintain the integrity of our federal programs.”

“Kickback schemes will always be an investigative priority for the FBI,” said Special Agent in Charge Matthew Fodor of the FBI Tampa Field Office. “Our mission is to protect the American people which includes safeguarding them from deceitful actions threatening our nation’s federal healthcare system.”

“Kickback arrangements can corrupt legitimate medical decision-making and undermine the integrity of federal healthcare programs,” said Acting Special Agent in Charge Ryan P. Lynch of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG). “HHS-OIG, working with our law enforcement partners, will continue to investigate improper billing and kickback schemes to protect both Medicare and Medicaid as well as those served by these programs.”

The civil settlement resolved a lawsuit filed under the qui tam or whistleblower provision of the False Claims Act, which permits private parties to file suit on behalf of the United States for false claims and share in a portion of the Government’s recovery. The qui tam was filed by a whistleblower who will receive $116,850 in connection with the settlement.

The settlement was the result of a coordinated effort between the Civil Division’s Commercial Litigation Branch, Fraud Section, and the U.S. Attorney’s Office for the Middle District of Florida, with assistance from HHS-OIG and the FBI. The United States previously resolved allegations that another ophthalmology practice in Florida engaged in a similar scheme with the same third-party TCD provider.

The government’s pursuit of this matter illustrates the government’s emphasis on combating healthcare fraud. One of the most powerful tools in this effort is the False Claims Act. Tips and complaints from all sources about potential fraud, waste, abuse, and mismanagement can be reported to HHS at 1-800-HHS-TIPS (800-447-8477).

Trial Attorney Nelson Wagner in the Civil Division’s Commercial Litigation Branch, Fraud Section, and Assistant United States Attorney Mamie Wise for the Middle District of Florida handled the matter.

The claims resolved by the settlement are allegations only and there has been no determination of liability. 

Department of Justice
Office of Public Affairs

Source: Justice.gov