The United States Attorney’s Office District of Maryland announced on June 27, 2019 that Anne Arundel Medical Center (“AAMC”), located in Annapolis, Maryland, has agreed to pay the United States $3,154,000 to settle allegations under the False Claims Act that it submitted false claims to Medicare for services that were not medically necessary.
The federal government alleged that between January 1, 2010 and December 31, 2013, AAMC submitted false claims to Medicare, TRICARE, and the Federal Employees Health Benefits Program for Evaluation and Management (“E/M”) services related to its Anticoagulation Clinic (“the Clinic”) that were not medically reasonable and necessary at the same time it submitted and was paid for claims for the blood tests.
The Clinic opened in June 2007, to monitor outpatient’s anticoagulation therapy. Patients who take Coumadin or the generic equivalent have their blood routinely tested to monitor their clotting times. These tests are known as prothrombin time international normalized ration (PT-INR) tests. These tests measure how much time it takes for a patient’s blood to clot and can be billed by a clinic using Current Procedural Terminology (CPT) code 85610. If test results indicate the need to adjust a patient’s Coumadin dose, or the patient presented with a change in medical condition, the provider may perform, and submit a claim for, an E/M service.
Effective January 1, 2014, CMS updated the hospital outpatient prospective payment system by bundling PT-INR tests with E/M services, when E/M services were provided during the same visit. The new CPT code that the clinic would use is G0463. According to the settlement agreement, between January 1, 2014 and December 31, 2017, AAMC submitted false claims to Medicare for both the bundled code G0463 and CPT 85610, notwithstanding that the PT-INR tests were included in G0463 claims.
The federal government alleged that for the time period before January 1, 2014, a substantial percentage of the claims for CPT 99211 submitted by AAMC were not medically reasonable and necessary when submitted with CPT 85610. The federal government further alleged that after January 1, 2014, all claims submitted by AAMC for CPT 85610 represented false claims when submitted with G0463.
Contemporaneous with the civil settlement, AAMC entered into a five-year Corporate Integrity Agreement (“CIA”) with the HHS-OIG which requires, among other things, the implementation of a risk assessment and internal review process designed to identify and address evolving compliance risks on an ongoing basis. The CIA requires training, auditing, and monitoring designed to address the conduct at issue in the case.
The settlement resolves a lawsuit brought by a former AAMC employee under the qui tam (whistleblower) provisions of the False Claims Act, captioned United States, et al. ex rel. McHenry v. Anne Arundel Medical Center, Case No. ELH-15-1256. As part of the settlement, the whistleblower will receive $473,100.
If you have information regarding false claims having been submitted to Medicare, Medicaid, other federal health care programs, or to other federal agencies/programs, and the information is not publically known and no actions have been taken by the government with regard to recovering the false claims, you should promptly seek to consult with a False Claims Act attorney (also known as qui tam attorneys) in Maryland or in your U.S. state who may investigate the basis of your False Claims Act allegations and who may assist you in bringing a qui tam lawsuit on behalf of the United States, if appropriate, for which you may be entitled to receive a portion of the recovery received by the U.S. government.
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