Physician Partners of America to Pay $24.5M to Settle Allegations of Unnecessary Testing, Improper Physician Compensation and Misrepresentation in Relation to COVID-19 Relief Funds | Takeover bid

Physician Partners of America LLC (PPOA), headquartered in Tampa, Florida, its founder, Rodolfo Gari, and its former chief medical officer, Dr. Abraham Rivera, have agreed to pay $24.5 million to resolve the allegations that they violated the False Claims Act by charging federal health care programs for unnecessary medical tests and services, paying illegal compensation to its employed physicians, and making a false statement in connection with a loan obtained by through the Small Business Administration (SBA) Paycheck Protection Program (PPP). Certain PPOA-affiliated entities are jointly and severally liable for the settlement amount, including Florida Pain Relief Group, Texas Pain Relief Group, Physician Partners of America CRNA Holdings LLC, Medical Tox Labs LLC, and Medical DNA Labs LLC.

The United States alleged that the PPOA caused the submission of medically unnecessary urine drug test (UDT) requests, by causing its physician employees to order multiple tests at the same time without determining whether a test was reasonable and necessary. , or even reviewing initial test results (presumptive UDT) to determine if further testing (definitive UDT) was warranted. The PPOA-affiliated toxicology lab then billed federal health care programs for the higher-level UDT. In addition, the PPOA incentivized its physician employees to order presumptive UDT by paying them 40% of profits from such tests in violation of the Stark Act, which prohibits physicians from referring patients to receive “designated health services.” payable to Medicare or Medicaid by entities. with whom the physician or an immediate family member has a financial relationship, with some exceptions.

The United States further alleged that the PPOA required patients to submit to genetic and psychological testing before patients were seen by doctors, without determining whether the tests were reasonable and necessary, and then charged for care programs. federal health authorities for testing.

The United States further alleged that when Florida suspended all non-emergency medical procedures to reduce transmission of COVID-19 in March 2020, the PPOA sought to compensate for lost revenue by requiring its employed physicians to schedule appointments. unnecessary evaluation and management (E/M) appointments. with patients every 14 days, instead of every month, as was previously the case for PPOA. The PPOA then instructed its physicians to bill for these E/M visits using inappropriate high-level procedure codes. Further, the United States alleged that at the same time that PPOA engaged in this illegal overcharging, PPOA falsely stated to the SBA that it was not engaging in illegal activity in order to obtain a loan of 5, $9 million through PPP. The settlement announced today resolves liability under the False Claims Act and the Financial Institutions Reform, Recovery and Enforcement Act (FIRREA) arising from false claims submitted to federal health care programs for E/M visits as well as for PPOA’s misrepresentation under its PPP Loan.

“Charging federal health care programs for services that providers know are unnecessary or unreasonable compromises the quality of care patients receive and increases the costs of these taxpayer-funded programs,” the assistant deputy attorney general said. principal Brian M. Boynton, head of the Department of Justice. Civil division. “The department is committed to ensuring that health care providers base their treatment decisions on the needs of their patients rather than their own financial interests.”

“Holding healthcare providers accountable for inflated claims and misrepresentations helps ensure the integrity of the healthcare system as a whole,” said U.S. Attorney Roger B. Handberg for the Central District of Florida. “Settlements like this are an important step in that direction.”

“Since the start of the pandemic, the SBA has been focused on providing prompt, fair and effective relief to millions of struggling small business owners – ensuring that relief was delivered with the utmost integrity a been at the heart of this mission under Administrator Guzman,” said General Counsel Peggy Delinois Hamilton for the SBA. “The SBA takes fraud seriously and will continue to make it our priority to work alongside the Office of Inspector General to identify and address potential fraud to ensure proper administration of relief programs.”

As part of the settlement, PPOA also entered into a five-year Corporate Integrity Agreement (CIA) with the Office of the Inspector General of the US Department of Health and Human Services (HHS-OIG). As part of the CIA, the PPOA agreed to undertake significant compliance efforts, including: maintaining a compliance department, medical director, and oversight board; retain the services of a compliance expert; provide management certifications; maintain written standards, training and education; obtain several annual claims reviews by an independent review body; establishing a risk assessment and internal review process; and implement test referral tracking.

“When health care providers charge taxpayer-funded health care programs for medically unnecessary services, they are diverting public funds intended to help business owners during this pandemic,” the special agent in charge said. Omar Pérez Aybar of HHS-OIG. “Our agency will work with our law enforcement partners to thoroughly investigate healthcare fraud schemes.”

“This settlement allows OWCP to recover medical bill payments under the Federal Employees Compensation Act and return those funds to the Employees Compensation Fund,” said Director Christopher Godfrey of the Office of Department of Labor (DOL) Workers Compensation Programs (OWCP). . “The Office of Inspector General of the Department of Labor, along with the Offices of Inspector General (OIG) of various other agencies, devote significant investigative resources to detecting cases of possible abuse within the framework of the FECA program, and this settlement demonstrates the commitment of the DOL and its OIG to help ensure that funds issued under the program are paid appropriately. »

“When actors in our health care system focus on profit rather than patient care, it undermines the integrity of the medical decision-making process,” said Special Agent in Charge Cynthia A. Bruce of the Department of Health. Defense Inspector General’s Office, Defense Criminal Investigation Service (DCIS), Southeast Field Office. “DCIS will continue to work with our investigative partners to protect the funding entrusted to the Defense Health Agency that serves our service members and their families.”

“Veterans Affairs Community Care Programs provide veterans and their families with the opportunity to obtain essential health services from providers within their own communities,” said Special Agent in Charge David Spilker of the office. from the Department of Veterans Affairs Office of Inspector General (VA OIG) Southeast Field Bureau. “This civil settlement reinforces the VA OIG’s commitment to protecting the integrity of VA health care programs and operations and safeguarding taxpayer funds.”

“When providers submit false claims for medically unnecessary testing, they not only violate their patients’ trust, but also compromise the integrity of the Federal Employee Health Benefits Program (FEHBP),” the special agent said. US office manager Amy K. Parker. of Personnel Management, Office of Inspector General (OPM OIG). “This settlement demonstrates OPM OIG’s commitment to protecting patients from testing that is not medically reasonable or necessary and to protecting FEHBP from fraudulent claims.”

The civil settlement includes the resolution of claims brought under the who tam or the whistleblower provisions of the False Claims Act by Donald Haight, Dawn Baker, Dr. Harold Cho, Dr. Venus Dookwah-Roberts and Dr. Michael Lupi, who are current or former employees of PPOA or its affiliated entities. Under these provisions, a private party can sue on behalf of the United States and receive a portion of any recovery. the who tam cases are subtitled United States ex rel. Haight c. Physician Partners of Am.; United States ex rel. Baker vs. Physician Partners of Am LLC; United States ex rel. Lupi c. Physician Partners of Am. SARL; and United States ex rel. Dookwah-Roberts v. Physician Partners of Am. SARL.

The resolution achieved in this case is the result of a coordinated effort between the Civil Division of the Department of Justice, Commercial Litigation Branch, Fraud Section; the United States Attorney’s Office for the Central District of Florida; HHS-OIG; VA IGO; CCIS; DOL OIG; and OPM OIG.

The investigation and resolution of this case illustrates the government’s focus on combating health care fraud. One of the most powerful tools in this effort is the False Claims Act. Tips and complaints from all sources regarding potential fraud, waste, abuse, and mismanagement may be reported to the Department of Health and Human Services at 800-HHS-TIPS (800-447-8477).

On May 17, 2021, the Attorney General established the COVID-19 Fraud Enforcement Task Force to mobilize Department of Justice resources in partnership with government agencies to scale up enforcement and prevention efforts. pandemic-related fraud. The task force strengthens fraud prevention efforts, among other methods, by augmenting and incorporating existing coordination mechanisms, identifying resources and techniques to uncover fraudulent actors and their schemes, and sharing and leveraging information and knowledge gained from previous enforcement efforts. For more information about the department’s response to the pandemic, please visit https://www.justice.gov/coronavirus. Advice and complaints from all sources regarding potential fraud affecting government COVID-19 relief programs may be reported by visiting the Civil Division’s Fraud Section webpage, which can be found here. Anyone with information about alleged attempted fraud involving COVID-19 can also report it by calling the Department of Justice’s National Center for Disaster Fraud (NCDF) hotline at 866-720-5721 or via the NCDF online complaint at: https://www.justice.gov/disaster-fraud/ncdf-disaster-complaint-form.

The case was handled by lead trial counsel David W. Tyler for the Civil Division and Assistant U.S. Attorney Lindsay Saxe Griffin for the Central District of Florida.

The claims resolved by the settlement are allegations only and no liability has been determined.

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