The U.S. Department of Justice (DOJ) announced on April 12 that Tampa-based Physician Partners of America LLC (PPOA), its founder Rodolfo Gari, and its former chief medical officer Dr. Abraham Rivera will pay $24.5 million to settle allegations that they violated the False Claims Act. The settlement resolves allegations that several whistleblowers filed in a qui tam complaint.
The qui tam provisions of the False Claims Act enable private citizens to file lawsuits on behalf of the government if they know of an individual or company defrauding the government. Qui tam whistleblowers are eligible to receive between 15 and 30% of the government’s recovery, if one occurs. In this case, five “current or former employees of PPOA or its affiliated entities” were the ones to blow the whistle.
The government alleged that “PPOA caused the submission of claims for medically unnecessary urine drug testing (UDT).” According to the press release, PPOA allegedly required physicians “to order multiple tests at the same time without determining whether any testing was reasonable and necessary, or even reviewing the results of initial testing (presumptive UDT) to determine whether additional testing (definitive UDT) was warranted.” The DOJ alleged that “PPOA’s affiliated toxicology lab then billed federal healthcare programs for the highest-level UDT.”
Additionally, PPOA allegedly “incentivized its physician employees to order presumptive UDT by paying them 40% of the profits from such testing,” behavior outlawed in the Stark Law. The law “prohibits physicians from referring patients to receive ‘designated health services’ payable to Medicare or Medicaid from entities with which the physician or an immediate family member has a financial relationship, unless an exception applies.”
PPOA also allegedly “required patients to submit to genetic and psychological testing before the patients were seen by physicians” and billed these tests to federal healthcare programs; however, PPOA allegedly did not make “any determination as to whether the testing was reasonable.”
The government alleged that PPOA also engaged in illegal activity related to the COVID-19 pandemic. In March 2020, Florida “suspended all non-emergency medical procedures to reduce transmission of COVID-19.” PPOA allegedly engaged in overbilling “by requiring its physician employees to schedule unnecessary evaluation and management (E/M) appointments with patients every 14 days, instead of every month as had been PPOA’s prior practice. PPOA then instructed its physicians to bill these E/M visits using inappropriate high-level procedure codes.”
This case also involved the Paycheck Protection Program (PPP), the loan program run by the Small Business Administration (SBA) designed to help businesses continue to function and keep employees on the payroll during the early days of the COVID-19 pandemic. The government alleged that PPOA represented to the SBA that it was not engaged in unlawful activity and proceeded to be awarded a $5.9 million PPP loan.
“The settlement announced today resolves liability under the False Claims Act and the Financial Institutions Reform, Recovery and Enforcement Act (FIRREA) arising from the false claims submitted to federal healthcare programs for the E/M visits as well for PPOA’s false statement in connection with its PPP loan,” the press release states.
As part of the settlement, “PPOA also entered into a five-year Corporate Integrity Agreement (CIA) with the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG).” PPOA will implement several changes because of the CIA including: “maintain a compliance department, medical director and oversight board; retain a compliance expert; provide management certifications; maintain written standards, training and education; obtain multiple annual claims reviews by an Independent Review Organization; establish a risk assessment and internal review process; and implement monitoring of testing referrals.”
Five whistleblowers who currently or formerly worked for PPOA “or its affiliated entities” — Donald Haight, Dawn Baker, Dr. Harold Cho, Dr. Venus Dookwah-Roberts and Dr. Michael Lupi — were named in the press release. The press release did not disclose whether or not the whistleblowers would get a monetary share of the settlement.
“Billing federal healthcare programs for services that providers know are unnecessary or unreasonable undermines the quality of care that patients receive and increases the costs of these taxpayer-funded programs,” said Principal Deputy Assistant Attorney General Brian M. Boynton, head of the Justice Department’s Civil Division, in the press release.
In Fiscal Year 2021, whistleblowers helped the U.S. Department of Justice (DOJ) recover $1.6 billion in settlements. The DOJ highlighted health care fraud as “the leading source of the department’s False Claims Act settlements and judgments.” This case exemplifies whistleblowers’ importance to protecting federal healthcare programs and, in turn, the patients who benefit from these programs.