Consumer Fraud

Whistleblower Helps U.S. Nab California Urology Chain For Medicare Fraud

Pills Stethascope on Money 435x289 Whistleblower Helps U.S. Nab California Urology Chain For Medicare FraudA whistleblower’s False Claims Act lawsuit has led to a $1.85 million settlement between Skyline Urology and the U.S. government, resolving allegations that the Torrance, California-based health care company deliberately overbilled Medicare.

Federal prosecutors investigated the whistleblower’s claims and alleged that from January 1, 2013, through 2016, Skyline Urology systematically billed Medicare for evaluation and management services in violation of federal rules.

Although some exceptions exist, health care providers are not permitted to bill Medicare for evaluation and management services on the same day a related procedure is performed. This is because the cost of evaluating a patient is included in the cost of a resulting procedure.

Health care providers may bill Medicare for evaluation and management services when they are completely separate from the other services provided and certain other circumstances. In those exceptions, health care providers can bill for both the evaluation and management services and the procedure by billing Medicare with a special code.

According to the whistleblower complaint, Skyline Urology knowingly used the code to falsify claims and overcharge the government, resulting in higher Medicare reimbursements.

As part of the settlement, Skyline entered into a Corporate Integrity Agreement with the U.S. Department of Health and Human Services, requiring closer oversight and regular monitoring of its billing practices for a three-year period.

“The U.S. Attorney’s Office for the District of Maryland is committed to thoroughly investigating claims of fraud and holding health care providers accountable when they break the rules,” said U.S. Attorney Robert K. Hur. “This settlement is an example of how whistleblowers and government can work together to recoup funds and deter overbilling practices.”

The whistleblower in this case, James Cesare, will receive $323,750 of the total settlement as an award for helping the U.S. recover the Medicare funds.