Georgia Cancer Specialists Overbilled Medicare for Evaluation and Management Services
ATLANTA—The United States Attorney’s Office for the Northern District of Georgia announced today that it has reached a settlement with Georgia Cancer Specialists I PC, which agreed to pay $4.1 million to settle claims that it violated the False Claims Act by billing Medicare for evaluation and management services that were not permitted by Medicare rules. Georgia Cancer Specialists is one of the largest private oncology practices in the country with 27 offices located throughout the Atlanta metro area.
Sally Quillian Yates, United States Attorney for the Northern District of Georgia, said, “Health care providers should be on notice that if they inflate their billings, we will aggressively seek to recover not only the overcharges but also significant penalties under the False Claims Act.”
Ricky Maxwell, Acting Special Agent in Charge, FBI Atlanta Field Office, stated, “The FBI continues to do its part in ensuring that federal funds appropriated to Medicare are spent appropriately and today’s settlement is an example of those efforts. The FBI urges anyone with information related to overbilling or fraudulent billing of our Medicare programs to contact their nearest FBI field office.”
“Today’s settlement sends a clear message to health care providers across the country that they will be held responsible if they misrepresent the services they bill to Medicare,” said Derrick L. Jackson, Special Agent in Charge of the U.S. Department of Health and Human Services, Office of Inspector General for the Atlanta region. “The Office of Inspector General will continue to work closely with our law enforcement partners to stamp out fraud, waste, and abuse within the Medicare system.”
The civil settlement resolves the United States’ investigation into Georgia Cancer Specialists’ practices relating to billing for evaluation and management (E&M) services on the same day as a related procedure. Generally, providers are not permitted to bill both E&M services and a related procedure on the same day under the Medicare program’s regulations. In specific circumstances, providers can avoid this prohibition by submitting their claims marked with modifier-25, which tells Medicare to pay both the procedure and the E&M service. Here, the U.S. Attorney’s Office alleged that Georgia Cancer Specialists applied modifier-25 to claims that did not qualify for its use, leading to overpayments by Medicare.
Because of widespread abuse of the use of modifier-25, the U.S. Department of Health and Human Services, Office of Inspector General, has targeted the use of modifier-25 in its yearly work plans. The yearly work plans outline the current focus areas of the OIG and lead to increased scrutiny by the OIG of those areas. The focus on the abuse of the use of modifier-25 was prompted because prior OIG work has shown that improper use of the modifier resulted in inappropriate payments to Medicare providers.
This resolution is part of the government’s emphasis on combating health care fraud under the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced by Attorney General Eric Holder and Kathleen Sebelius, Secretary of the Department of Health and Human Services in May 2009. The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation. One of the most powerful tools in that effort is the False Claims Act, which the Justice Department has used to recover more than $9.2 billion since January 2009 in cases involving fraud against federal health care programs. The Justice Department’s total recoveries in False Claims Act cases since January 2009 are over $12.8 billion.
This case was investigated by special agents of the Federal Bureau of Investigation and Health and Human Services, Office of Inspector General. The civil settlement was reached by Assistant United States Attorney Christopher J. Huber.
The claims settled by the settlement agreement are allegations only; there has been no determination of liability.
For further information please contact the U.S. Attorney’s Public Information Office at USAGAN.Pressemails@usdoj.gov or (404) 581-6016. The Internet address for the HomePage for the U.S. Attorney’s Office for the Northern District of Georgia is www.justice.gov/usao/gan.