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Catch of the Week: Ophthalmology group, former CEO, and individual physicians settle fraud claims for $6.65M

Posted  October 11, 2019

Our latest Catch of the Week highlights the successful resolution of a whistleblower lawsuit against a Southern California eye doctor group and several individuals allegedly embroiled in a decade-long scheme to bill publicly funded healthcare programs for unnecessary eye exams.  Ophthalmology provider group Retina Institute of California Medical Group (RIC), its former CEO, several of its doctors, and other involved entities collectively paid the United States and California a combined $6.65 million to resolve the allegations.

The whistleblower duo, two former RIC administrators Bobbette A. Smith and Susan C. Rogers, filed the lawsuit on the Government’s behalf under the False Claims Act’s (“FCA”) qui tam provisions.  They effectively pursued their claims after the United States declined to intervene in the action.  As the FCA contemplates, Smith and Rogers will receive a share of the settlement as a reward for their courage and persistence in holding the defendants responsible for defrauding the Government and taxpayers.

Over a ten-year period, defendants allegedly falsely billed Medicare and Medicaid for more complex eye exams than were necessary or performed, improperly submitting billing codes reserved for exams performed on patients with more severe conditions than patients in fact had.  In addition, the settlement resolves claims that RIC and other defendants induced patient referrals by waiving deductibles and copayments without documenting the patients’ financial need.  Finally, defendants also allegedly billed federal and state programs for medical services that weren’t performed, were unnecessary, not documented, or were otherwise non-compliant with rules and regulations.

The Justice Department announced the settlement in an October 4, 2019 press release.


Tagged in: Catch of the Week, FCA Federal, Medical Billing Fraud, Other Government Health Programs, Provider Fraud,