Knoxville, Tenn. – Southeastern Retina Associates (“SERA”) has paid $1.5 million to resolve False Claims Act allegations in the United States District Court for the Eastern District of Tennessee.
As part of the settlement, SERA entered into a five-year Corporate Integrity Agreement (CIA) with the U.S. Department of Health and Human Services, Office of the Inspector General (HHS-OIG), requiring the implementation of a risk assessment and internal review process designed to identify and address evolving compliance risks. The CIA requires training, auditing and monitoring designed to address the conduct at issue in the case. Southeastern Retina Associates has over 250 employees in offices throughout eastern and middle Tennessee, northern Georgia, and southwestern Virginia.
The settlement resolves allegations that, from 2009 through 2016, the practice improperly used the Modifier 25 billing code to charge Medicare and Medicaid for exams that were not separately billable from other procedures performed on the same day. The settlement also resolves allegations that certain Medicare and Medicaid billings during the same period included charges for exams at higher levels than appropriate.
“It is important that medical providers present appropriate and reasonable charges for services that are paid for by the taxpayers. This office remains committed to ensuring that publicly funded healthcare systems are not charged more than what the billing rules prescribe,” said U.S. Attorney J. Douglas Overbey.
“Healthcare fraud and abuse impacts every American. The critical resources that are removed from our health care system due to exploitation results in higher health care cost for everyone. The FBI will continue to work closely with federal, state, and local partners to investigate those who abuse federally funded healthcare programs,” said Joseph E. Carrico, Special Agent in Charge of the Knoxville Division of the Federal Bureau of Investigation.
“We will continue to pursue doctors that use deceptive billing practices to make more money. These types of schemes cost federal health care programs millions of dollars and cheat taxpayers in the process,” said Derrick L. Jackson, Special Agent in Charge at the U.S. Department of Health and Human Services, Office of Inspector General in Atlanta.
“The Department of Veterans Affairs Office of Inspector General is committed to working with our law enforcement partners to identify and investigate those who defraud or abuse VA’s healthcare system. This settlement shows that VA-OIG will continue to aggressively investigate anyone who overbills VA programs intended to care for our nation’s veterans,” said Kim R. Lampkin’s, Special Agent in Charge of VA-OIG’s Mid-Atlantic Field Office.
“False claims that overbill the federal healthcare programs undermine the integrity of the Federal Employees Health Benefits program and increase the cost of medical care for us all. OPM-OIG thanks the U. S. Attorney’s Office and our law enforcement partners. Today’s settlement demonstrates joint commitment to investigating and prosecuting fraudulent billing practices that waste taxpayer dollars,” said Thomas W. South, Deputy Assistant Inspector General, Office of the Inspector General (OPM-OIG).
This investigation was the result of a coordinated effort by the U.S. Attorney’s Office for the Eastern District of Tennessee, U.S. Department of Health and Human Services Office of Inspector General, U.S. Office of Personnel Management, Knoxville Division of the FBI, and the Tennessee Attorney General’s Office. The investigation was prompted by a lawsuit filed in 2015 under the qui tam or “whistleblower” provisions of the False Claims Act, which permit private individuals to sue on behalf of the government for false claims and to share in any recovery. The relator’s share of the recovery in this case will be $270,000.
Assistant United States Attorneys Jessica Sievert, Jeremy Dykes, and Rob McConkey, represented the United States.
The claims settled by this agreement are allegations only; there has been no determination of liability.