Last week, a prominent Atlanta cancer treatment practice reached a settlement agreement with the Department of Justice to resolve allegations that it over-billed Medicare. Georgia Cancer Specialists is one of the largest oncology providers in the country and has 27 offices in Georgia. The company has not released a statement yet and though it has agreed to pay $4.1 million as part of a settlement, GCS has not actually admitted fault or liability.
According to the government, GCS violated Medicare regulations when it billed the federal program for “evaluation and management” for services provided on the same day as medical procedures that were also billed to the government. Employees at GCS were well aware that the normal rules did not permit such double billing, but they also knew that Medicare provided a special mechanism to get around this rule. When special circumstances arise, healthcare providers are permitted to bill simultaneously for both evaluation and management as well as medical procedures by using the billing code “-25.”
Essentially, the government argues that GCS billed Medicare with the special code when no special circumstances were present. This caused overbilling when GCS got paid twice for services Medicare should only cover once.
In this case, GCS’s alleged fraud seems to have been discovered by the Department of Health and Human Services’ Office of the Inspector General. Knowing that misuse of the “-25” code had become widespread, the office investigated GCS when it noted the code being used disproportionately.
In many cases, however, deceptive billing practices have not yet come to the government’s attention and federal inspectors are less likely to find illegal practices on their own. In these circumstances, the role of whistleblowers is essential in uncovering fraud and recovering taxpayer funds wrongfully taken. Healthcare fraud in particular has become a central focus of the Obama Administration’s Justice Department with $4 billion in healthcare recoveries under the False Claims Act in 2011 alone. Whistleblowers with original evidence of deceptive billing practices or fraud against federal healthcare programs stand to receive generous awards if they file successful qui tam lawsuits against perpetrators.