Compliance

A Simple Rule For Compliance: Clinical Need Not Fiscal Greed

01/16/2023

OK, it’s a softball question: When is it improper to bill for a case?

The answer: When the patient didn’t need the procedure in the first place.

If everyone were as smart as you, but not smarter because maybe that’s the problem, we’d have no False Claims Act settlements like the one recently entered into by Aarti D. Pandya, M.D., and her medical group, Aarti D. Pandya, M.D. P.C. (“Pandya Practice Group” or the “Practice”). Note that the settlement is of civil, not criminal claims, and that it resolves allegations only, there having been no determination of liability.

The settlement in the amount of approximately $1,850,000 arose as a result of a False Claims Act case, commonly referred to as a whistleblower lawsuit, initially brought by Laura Dildine, a former Pandya Practice Group employee. The suit centered around allegations that Dr. Pandya and her Practice:

  • Knowingly submitted false claims to federal healthcare programs for medically unnecessary cataract extraction surgeries and YAG laser capsulotomies.
  • That Dr. Pandya performed these procedures on patients that did not qualify for the procedure under accepted standards of medical practice and, in some cases, caused injury to her patients.
  • That Dr. Pandya falsely diagnosed patients with glaucoma to justify unnecessary diagnostic testing and treatment that was billed to Medicare.
  • That many of the diagnostic tests that Dr. Pandya ordered were not properly performed, were performed on a broken machine, or were not interpreted in the medical record, as required by Medicare.

Here are some general observations on cases of this type, all valuable takeaways for you:

  1. False Claims Act settlements, being civil, not criminal, cases, generally resolve only the civil allegations. Any potential criminal liability remains unresolved.
  2. Depending on the type of allegations in a False Claims Act case, the underlying facts might trigger prosecution for a wide range of criminal activity, from federal healthcare fraud to state law crimes such as battery.
  3. Additionally, the allegations underlying a False Claims Act case might support state medical board action.

Remember, False Claims Act cases often arise from whistleblowers within the medical practice or healthcare organization. I’m not suggesting a support group for fraudsters “victimized” by their own staff; rather, I’m simply pointing out that anyone engaged in what appears to be fraudulent activity has to be worried about more than payors and “the police”, they have to be worried about those on their own payroll, too.



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