A whistleblower who sued San Diego health care system Scripps Health alleging it improperly charged Medicare and another government health care program for physical therapy services has helped the U.S. government recover $1.5 million.
The U.S. Justice Department (DOJ) and the whistleblower complaint alleged that Scripps Health submitted false claims to the Medicare and TRICARE programs for physical therapy services provided by therapists who lacked the proper credentials and billing privileges and were not supervised by a physician or other qualified health care provider.
According to the DOJ, Medicare and TRICARE – the health care program for active servicemembers and their families – limit billing privileges to enrolled providers only. Services from unenrolled providers can be billed as “incident to” the services of an enrolled physician, but only if the physician provided direct supervision.
The whistleblower complaint asserted that Scripps billed the government health care programs for physical therapy services provided by therapists without the proper billing privileges with Medicare or TRICARE and without the appropriate supervision by a physician.
The federal health care programs require that services are provided by authorized medical professionals or rendered under the supervision of an enrolled physician.
“These requirements help protect patients from unscrupulous or unqualified medical professionals,” said Chad A. Readler, Acting Assistant Attorney General for the Justice Department’s Civil Division.
Billing the government for services that do not meet the requirements for Medicare and other federal health care programs may be considered a submission of false claims.
According to the DOJ, the settlement resolves allegations filed in a lawsuit by Suzanne Forrest, a former Scripps Health employee, under the whistleblower provisions of the False Claims Act, which permit private parties to sue for false claims on behalf of the government and to share in any recovery.
Ms. Forrest filed the whistleblower lawsuit in a Southern California federal court. She will receive $225,000 as a whistleblower award for helping the government recover the health care funds.
Scripps denies wrongdoing and says it self-disclosed the billing errors, which it attributed to a technical issue, to the government unaware of the whistleblower lawsuit. “Scripps diligently investigated the issue and attempted to resolve it through appropriate channels,” the nonprofit health care provider said in a statement.