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Catch of the Week: New York-Presbyterian Hospital

Posted  January 26, 2024

This week’s Department of Justice (DOJ) Catch of the Week goes to New York-Presbyterian Hospital.  Yesterday (January 25), the hospital agreed to pay $801,000 to settle charges it violated the False Claims Act by billing Medicare, Medicaid and TRICARE for medically unnecessary images for radiation therapy treatments provided to cancer patients.

The settlement is notable not for the relatively small amount of money New York-Presbyterian paid out, but for the nature of the conduct with which the government took issue.  It involved the delivery of image guided radiation therapy treatments (IGRT), which is a type of cancer treatment that uses imaging technologies (like PET, MRI, and CT scans) to deliver radiation more accurately and safely.

According to the government, two New York-Presbyterian affiliated oncology groups — Radiation Therapist Associates and Leading Edge Radiation Oncology Services — used IGRT to provide outpatient radiation oncology services to several Brooklyn communities.  The problem was they billed the government for the IGRT images even when they never reviewed them or reviewed them too late to be useful.

The government viewed the images under these circumstances as not medically reasonable and necessary, which is a prerequisite for government reimbursement.  Breon Peace, United States Attorney for the Eastern District of New York, which led this enforcement action, went even further in describing this conduct:

The defendants provided substandard care to cancer patients by not properly or timely reviewing medical imaging and then billed taxpayer funded healthcare programs for these shoddy services.

The government routinely brings False Claims Act cases against healthcare providers that bill Medicare/Medicaid for medically unnecessary services.  But this case would seem to take the standard to a new level.  It shows the government is willing make the assessment not only on the medical need for the actual service, but also on how the healthcare provider follows up after the service is performed.  It is definitely a case healthcare providers and their compliance professionals should keep in mind going forward.

Like the majority of False Claims Act actions, this one involved allegations brought by a whistleblower under the qui tam provisions of the False Claims Act, which allows private individuals to bring lawsuits against those defrauding the government.  In return, successful whistleblowers are entitled to up to 30% of the government’s recovery.  Over the past 25 years, whistleblowers have recovered billions of dollars in whistleblower rewards under the False Claims Act and have been responsible for tens of billions of dollars in government recoveries.

The government did not identify the whistleblower in this matter or the whistleblower award they will receive.

If you would like more information on what it means to be a whistleblower or think you may have information relating to healthcare fraud or any other kind of government contract fraud, please feel free to contact us so we can connect you with a member of the Constantine Cannon whistleblower lawyer team for a free and confidential consultation.

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Tagged in: Catch of the Week, FCA Federal, Healthcare Fraud, Lack of Medical Necessity, Medicaid, Medicare, Other Government Health Programs, Whistleblower Case,