Doctors Care, P.A. (“Doctors Care”) and UCI Medical Affiliates of South Carolina, Inc. (“UCI”), have agreed to pay $22.5 million to settle alleged False Claims Act (FCA) violations, according to an April 8 U.S. Department of Justice (DOJ) press release. UCI manages Doctors Care, which is South Carolina’s largest urgent care provider network.
The qui tam lawsuit was brought by whistleblowers who claim UCI and Doctors Care submitted bills for urgent care visits performed by medical providers who were not credentialled to bill Medicaid, Medicare, and TRICARE. In order to bill federal medical programs, all medical providers must have certain certifications.
Whistleblowers allege that between 2013 and 2018, UCI did not secure federal medical program billing credentials for many of their Doctors Care providers, yet billed Medicaid, Medicare, and TRICARE anyway. Federal insurance companies require that providers who regularly bill federal medical programs acquire and routinely renew their billing credentials. The lawsuit alleges that instead of going through the normal process of acquiring new billing credentials, UCI grouped their providers who had billing credentials with those that did not. This allowed the company to bill the medical programs without going through the process for all of their providers.
The government claims to have evidence that UCI was aware of these alleged violations in the form of emails and “cheat sheets.” The DOJ claims that these documents demonstrate how UCI linked uncredentialed providers with credentialed providers, allowing many of their providers to slip under the radar for years.
Derrick L. Jackson, Special Agent in Charge of the Office of Inspector General for the U.S. Department of Health and Human Services stated that: “Taxpayers and Medicare patients rightly expect medical providers to be properly credentialed before billing for their services. Working with our law enforcement partners, we will continue protecting Federal healthcare programs.” The government asserts that even though “there is no evidence in this case that any Doctors Care provider lacked a medical license or that patient care was compromised due to the conduct at issue,” billing federal medical programs without going through the proper processes is fraud, and will be punished as such.
UCI and Doctors Care have also agreed to enter a Corporate Integrity Agreement (CIA) that requires them to pay for and work closely with an Independent Review Organization (IRO) that will oversee many of their future management decisions. The terms of the agreement will lock UCI and Doctors Care into a 5-year relationship with the IRO, during which the IRO will review the claims UCI and Doctors Care submit to federal medical programs. The government also notes that when UCI and Doctors Care were first confronted about the alleged violations, they cooperated with the government, “act[ing] promptly to investigate and stop the conduct subject to this settlement.”
The unnamed whistleblowers in the case are eligible for a total reward of 15 to 30% of the $22.5 million that the government will recover. This money will likely be split between however many whistleblowers there are. Qui tam whistleblower cases like this one are extremely effective at bringing cases of healthcare fraud to court. In 2020, over two-thirds of money recovered through the False Claims Act came from qui tam whistleblower cases, proving once again the importance of whistleblowers in False Claims Act recoveries.