Advanced Urology Pays $14M to Settle False Claims Act Allegations of Billing Medicare for Medically Unnecessary Services

By the Constantine Cannon Whistleblower Team

On April 2, the Department of Justice (DOJ) announced that Georgia-based Advanced Urology, Inc. and its founder Dr. Jitesh Patel will pay $14 million to settle allegations they violated the False Claims Act and Georgia False Medicaid Claims Act by billing for urology procedures that were medically unnecessary or not performed at all.[1]  Notably, DOJ highlighted that the action was prompted by two former Advanced Urology employees, including a physician who worked for the practice.

What Was the Basis of Advanced Urology’s Medical Necessity Fraud?

According to DOJ, the whistleblowers alleged that Dr. Patel designed his company to maximize revenue by engaging in the following medically unnecessary procedures and tests:

• • Implanting Sacral Nerve Stimulator devices without first determining whether the patients would benefit from the device.
  • Performing unnecessary Cystoscopy and Retrograde Pyelogram procedures, which involves inserting a scope through the patient’s urethra and into the bladder.
  • Performing Electromyography tests on most new patients even though these tests are rarely used in urology practices and involve transmitting electrical signals through an electrode attached to the patient’s genitalia.
  • Ordering thousands of unnecessary ultrasound tests, including duplex ultrasounds and retroperitoneal ultrasounds.
  • Billing for Direct Visual Internal Urethrotomy procedures never performed.

Medicare/Medicaid will only cover medical procedures and treatments that are medically necessary.  It is one of the essential requirements for Medicare/Medicaid reimbursement and one that the Government will aggressively enforce.

Is Medical Necessity Fraud a Government Priority Under the False Claims Act?

In announcing the settlement, the Government reinforced its zero-tolerance approach for going after this kind of healthcare fraud.  U.S. Attorney Theodore Hertzberg stressed that doctors “commit fraud when they seek payment for medically unnecessary procedures or bill for services they never performed,” and that his office “will not tolerate” this kind of misconduct.  His comments were followed by a string of equally forceful statements from several other Government officials warning healthcare providers to stay within the bounds of billing the Government only for medically necessary services.

According to Constantine Cannon whistleblower partner Marlene Koury who has represented healthcare fraud whistleblowers for more than 15 years, “Billing for medically unnecessary products or services is a well-trodden area of False Claims Act enforcement.”

“And it covers a wide swathe of fraudulent behavior,” Koury says, “not just products or services foisted upon patients who did not need them.”

Koury points to defective products and procedures, those provided by unqualified or unlicensed personnel, those that fail to comply with key regulatory or contractual requirements, and those that do not provide the intended or promoted effect or result as examples of the kind of intentional misbehavior that can fall under the medical necessity fraud umbrella.

But Koury cautions, the Government will shy away from those cases that involve medical judgment.  “It has to be clear that the healthcare provider intentionally provided a product or service it knew the patient did not need or from which the patient would not benefit.”  Unfortunately, Koury says, “We are seeing more and more whistleblowers come forward with evidence of just that.”

What Role Do Whistleblowers Play in Reporting Medical Necessity Fraud?

The vast majority of False Claims Act cases are brought by whistleblowers who because of their inside view of the company’s operations may be the only ones positioned to expose the fraud.  Under the qui tam provisions of the statute, successful whistleblowers are entitled to receive up to 30% of the Government’s recovery.  Former Advanced Urology employees Lorraine Perumal-Szramel and Dr. Himanshu Aggarwal were the whistleblowers in this action and will collectively receive a whistleblower award of $2,940,000 from the proceeds of the Government’s settlement.

Constantine Cannon Has Substantial Experience Representing Medical Necessity Fraud Whistleblowers

Constantine Cannon has substantial experience representing whistleblowers reporting medical necessity fraud.  If you would like to learn more about our successes in this area or what it means to be a whistleblower under the False Claims Act, please do not hesitate to contact us.  We will connect you with an experienced member of the Constantine Cannon Whistleblower Team for a free and confidential consultation.

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Sources:

[1]  See https://www.justice.gov/usao-ndga/pr/advanced-urology-and-jitesh-patel-will-pay-14-million-settle-false-claims-act-case.

Tagged in: False Claims Act, Medicaid, qui tam,