A Southern California-based ophthalmology group, its former chief executive and several of its physicians paid $6.65 million to settle allegations that they defrauded public health care programs by billing for unnecessary eye exams, improperly waiving Medicare co-payments and violating other regulations, the U.S. Department of Justice announced Friday.
Retina Institute of California Medical Group, a medical partnership of ophthalmologists who specialize in the treatment of retinal diseases, operates in multiple locations in Los Angeles, Orange and Riverside counties. Earlier this week, the RIC and other defendants paid the United States $6.35 million and paid California $296,590 under a settlement agreement, according to the DOJ.
The other defendants who participated in the settlement are: Dr. Tom S. Chang, of Pasadena; Tom S. Chang, M.D. Inc., a Pasadena-based company; Dr. Michael A. Samuel, of Arcadia; Dr. Michael J. Davis, also of Arcadia; Brett Braun, former CEO of Retina Institute of California Medical Group; California Eye and Ear Specialists, a Pasadena-based subsidiary of Trilogy Eye Medical Group Inc., a company for whom Chang and Samuel serve as senior executives; and San Gabriel Ambulatory Surgery Center LP, a San Gabriel-based company.
Between January 2006 and August 2017, the defendants violated the False Claims Act by submitting bogus claims to Medicare and Medicaid/Medi-Cal, according to the settlement agreement.
Medicare reimburses physicians for examining patients, paying more money as the medical exams performed increase in complexity. RIC personnel were accused of improperly billing public health programs by misclassifying simpler exams as being more complex, using billing codes normally used for patients with severe or emergency conditions, according to the DOJ.
RIC and the other defendants also waived Medicare co-payments and deductibles without proper documentation of patients’ financial hardship, which was intended to induce referrals. The defendants also billed Medicare and Medicaid for medical services that weren’t performed, were unnecessary, not documented in the medical record or were not in compliance with applicable rules and regulations, according to the DOJ.
The settlement stemmed from a whistleblower lawsuit filed in Los Angeles federal court by Bobbette A. Smith and Susan C. Rogers, who formerly worked for RIC as administrators, under the whistleblower provisions of the False Claims Act.
The provisions permit private individuals to sue on behalf of the government for false claims and to share in any recovery. The United States may intervene in the lawsuit, or, as in this case, the whistleblower may pursue the action. Smith and Rogers will receive a share of the settlement, but that amount has not yet been determined, DOJ officials said.
The case, which was filed in May 2013 and unsealed in July 2016, was monitored by the U.S. Attorney’s Office in Los Angeles, as well as the U.S. Department of Health and Human Services’ Office of Inspector General.
>> Want to read more stories like this? Get our Free Daily Newsletters Here!Follow us: