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April 15, 2021. The United States Department of Justice settled a case against Doctors Care, P.A., and its management company, UCI Medical Affiliates of South Carolina, Inc., an urgent care provider and its management company. Under the terms of the settlement, the urgent care company paid $22.5 Million.
According to the allegations, the urgent care provider falsely certified that urgent care visits were performed by providers who were credentialed to bill Medicaid, Medicare and TRICARE, although the services were actually performed by non-credentialed providers.
Federal health insurance companies require physicians and mid-level providers to obtain billing credentials. To bill government, health care programs for services provided to government-insured patients, doctors and certain medical service providers are required to apply for enrollment in the Medicare program. Medicare and its contractors who administer the programs review the representations and certifications made by the providers on their enrollment application and are responsible to determine whether to approve the physician or medical provider. Health care providers must certify on the application that they will comply with Medicare laws, regulations, and program instructions. It is alleged that UCI submitted false claims for payment by knowingly substituting credentialed billing providers for uncredentialed providers.
This settlement resolves a lawsuit brought by a whistleblower who is protected against retaliation under the whistleblower provisions of the False Claims Act. A whistleblower is also known as a “relator” under the Act. For demonstrating a commitment to protect the integrity of Medicaid, Medicare, and TRICARE programs, the whistleblower will receive between 15% and 25% of the recovery in this case, or $3,375,000 to $5,625,000. The Department of Justice needs whistleblowers to report healthcare fraud to help protect healthcare programs and patients, and to hold accountable any company that commits fraud, waste, or abuse in the Medicaid, Medicare, and TRICARE programs.
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© 2021 by Tycko & Zavareei LLPNational Law Review, Volume XI, Number 105
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Whistleblower Rewarded for Urgent Care Provider violations - The National Law Review
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