September 20, 2020

Volume X, Number 264

September 18, 2020

Subscribe to Latest Legal News and Analysis

September 17, 2020

Subscribe to Latest Legal News and Analysis

Series of 2019 Enforcement Actions Highlight Continued Federal and State Scrutiny of Health Care Billing in Connecticut

Since the beginning of 2019, federal and state authorities in Connecticut have announced a number of enforcement actions targeting alleged health care fraud in the state. These cases are a reminder to providers of heightened criminal and civil scrutiny of arrangements implicating health care fraud and abuse laws in the state, and also reflect the extensive federal-state cooperation between the Department of Justice (DOJ) and Office of the Attorney General (AG) in investigating fraud and abuse. That federal-state cooperation is part of Connecticut’s Interagency Fraud Task Force, an initiative started in 2013 to prosecute fraud that includes multiple Connecticut agencies, as well as DOJ and the Office of Inspector General (OIG) within the Department of Health & Human Services (HHS).

First, on January 29 the AG announced via press release that a behavioral analyst had entered into a $20,000 settlement with the AG tied to allegations of improper billing for autism spectrum disorder (ASD) services. According to the AG, the behavioral analyst was an enrolled provider in the state’s Medicaid program who furnished ASD services to Medicaid recipients that included diagnostic evaluations, behavioral assessments, development of plans of care, and medically necessary interventions. The AG alleged that the analyst submitted claims to the Medicaid program for services that were not performed, in violation of the Connecticut False Claims Act.  Specifically, the AG alleged that although ASD services are often performed in a patient’s home by a technician under direct observation by a behavioral analyst, the defendant submitted claims to the Medicaid program for direct observation and direction of the technician despite rarely actually being present in the home during such services. In addition to the monetary settlement, the defendant agreed to be suspended from participation in the Connecticut Medicaid program for a period of 3 years.

On March 7, DOJ issued a press release announcing a $467,000 settlement with a supplier of durable medical equipment (DME) and its owner to resolve allegations of violations of the federal and state False Claims Acts. According to DOJ, the DME supplier billed Medicaid for back braces and electrical stimulation units that were not provided or were not medically necessary. This enforcement action was another case of DOJ and the AG’s office working together to scrutinize billing under the state’s Medicaid program.

On March 15, DOJ announced a $3.38 million dollar settlement with a New London psychiatrist and his medical practice to resolve alleged federal and state FCA violations. According to DOJ, the medical practice provided behavioral health and addiction medicine services, and regularly conducted urine drug screening tests on patients to screen for multiple drug classes. Per DOJ, such testing should be billed only once per patient encounter (i.e., a single unit), but the medical practice allegedly submitted claims to Medicare for multiple units of urine drug screening tests per patient encounter, which resulted in the practice allegedly receiving Medicare payments it was not entitled to receive. DOJ further alleged that the practice submitted separate claims for alcohol testing conducted on the patient samples, despite the fact that alcohol testing was included in the drug screening test for which the practice was separately reimbursed by Medicare. Finally, DOJ alleged that the practice submitted claims for confirmation testing that was not actually performed, and improperly submitted claims to the state’s Medicaid program for specimen validity testing of urine samples. In addition to the monetary payment, the practice and its owner agreed to enter into a 3 year billing Integrity Agreement with HHS to “ensure future compliance with the requirements of federal healthcare programs.”

On March 18, 2019, a physician who formerly practiced in Norwalk was sentenced to 87 months in prison “for health care fraud and money laundering offenses” according to a DOJ press release. DOJ stated that the physician billed the Medicaid program for nearly $5 million dollars for home, office, and nursing home visits “that never occurred.”  In addition to imprisonment and 3 years of supervised release, the physician was ordered to pay nearly $5 million dollars in restitution, forfeit $50,000, and surrender his controlled substances registration to the Drug Enforcement Administration. Notably, this investigation is related to another criminal health care fraud prosecution concluded by DOJ in 2018, under which the physician-owner of the Norwalk practice pleaded guilty to writing “hundreds of medically unnecessary prescriptions for oxycodone and hydrocodone” and was sentenced to 54 months in prison.

Most recently, on April 4 DOJ announced that an oral surgeon and his former practice in New Haven agreed to a $252,000 settlement to resolve FCA allegations concerning fraudulent billing for oral surgery and maxillofacial services.  According to DOJ, the surgeon and/or the practice improperly submitted claims to Medicaid for sedation/anesthesia services that were not provided, for removal of bone or tissues that was either not performed or included in separate claims for reimbursement on the same day, and for surgical tissue reduction services that were not provided or were not medically necessary. This is another enforcement action that was spearheaded by the OIG and AG’s office, and represents an important reminder that the government will not hesitate to pursue providers for alleged fraud and abuse violations even after retirement or they have sold their practices.

Copyright © 2020 Robinson & Cole LLP. All rights reserved.National Law Review, Volume IX, Number 100

TRENDING LEGAL ANALYSIS


About this Author

Conor Duffy Cybersecurity Attorney
Associate

Conor Duffy is a member of the firm's Health Law Group and its Data Privacy + Cybersecurity Team. He advises hospitals, physician groups, community providers, and other health care entities on general corporate matters and health law issues. He also counsels clients on what measures are needed to safeguard data and patient information.

Regulatory

Conor provides legal counsel to health care clients on various regulatory matters, such as Medicare and Medicaid program compliance, federal fraud and abuse laws, and the Emergency Medical Treatment & Labor Act...

860.275.8342