On April 12, 2022, the DOJ in the Middle District of Florida Announced that Physician Partners of America Agreed to Pay $24.5 Million to Settle Allegations of Unnecessary Testing, Improper Remuneration to Physicians and a False Statement in Connection with COVID-19 Relief Funds
Physician Partners of America LLC, headquartered in Tampa, Florida, its founder, Rodolfo Gari, and its former chief medical officer, Dr. Abraham Rivera, have agreed to pay $24.5 million to resolve allegations that they violated the False Claims Act. The violations alleged by the DOJ were:
- Billing federal healthcare programs for unnecessary medical testing and services;
- Paying unlawful remuneration to its physician employees; and,
- Making a false statement in connection with a loan obtained through the Small Business Administration’s (SBA) Paycheck Protection Program (PPP).
The government, and individual Relator whistleblowers, alleged that PPOA caused the submission of false claims for medically unnecessary urine drug testing (UDT). It did so by requiring its physician employees 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. That would piss anyone off, but more importantly, would be fraudulent.
To make matters worse, PPOA’s affiliated toxicology lab then billed federal healthcare programs for the highest-level UDT. Bu wait, there’s still more. PPOA also incentivized its physician employees to order presumptive UDT by paying them 40% of the profits from such testing. Yup, kickbacks alleged. This violates Stark Law, which 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 (some exceptions apply, but not here).
But wait, there’s more. The United States further alleged that PPOA required patients to submit to genetic and psychological testing. They required this testing before the patients were even seen by physicians and without making any determination as to whether the testing was reasonable and necessary. Naturally, they then billed federal healthcare programs for the tests.
I almost hate to say it, but wait, there is still more. The US also alleged that when Florida suspended all non-emergency medical procedures to reduce transmission of COVID-19 in March 2020, PPOA devised a fraudulent scheme to make up for the lost revenue. They did so by requiring its physician employees to schedule unnecessary evaluation and management (E/M) appointments with patients every 14 days. They required biweekly testing, instead of monthly, as had been PPOA’s prior practice. Incredibly, PPOA then instructed its physicians to bill these E/M visits using inappropriate high-level procedure codes. Talk about cheating US taxpayers in very way possible!
Getting a bit boring, I know, but the US also alleged that PPOA also falsely represented to the SBA that it was not engaged in unlawful activity in order to obtain a $5.9 million loan through the PPP.
The $24.5 Million settlement announced by the DOJ on April 12, 2022, resolves PPOA’s liability under the False Claims Act and the Financial Institutions Reform, Recovery and Enforcement Act (FIRREA). The settlement covered all of the claims alleged above for 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.
Principal Deputy Assistant Attorney General Brian M. Boynton, head of the Justice Department’s Civil Division, said in the DOJ Press Release announcing 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. The department is committed to ensuring that healthcare providers base their treatment decisions on their patients’ needs rather than their own financial interests.”
U.S. Attorney Roger B. Handberg for the Middle District of Florida, added that:
“Holding healthcare providers accountable for inflated claims and false statements helps ensure the integrity of the healthcare system as a whole. Settlements like this one are an important step in that direction.”
General Counsel Peggy Delinois Hamilton for the SBA said:
“Since the beginning of the pandemic, the SBA has been focused on providing relief swiftly, equitably and efficiently to millions of struggling small business owners – ensuring that relief has been distributed with the utmost integrity has been central to that mission under Administrator Guzman. The SBA takes fraud seriously and will continue to make it our priority to work alongside the Office of the Inspector General to identify and address any potential fraud to ensure sound administration of relief programs.”
In connection with 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). An agreement like that was certainly needed here. Under the CIA, PPOA agreed to undertake significant compliance efforts, 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.
The civil settlement includes the resolution of claims brought under the qui tam or whistleblower provisions of the False Claims Act by Donald Haight, Dawn Baker, Dr. Harold Cho, Dr. Venus Dookwah-Roberts and Dr. Michael Lupi. They are all current or former employees of PPOA or its affiliated entities. The qui tam cases they filed are captioned United States ex rel. Haight v. Physician Partners of Am.; United States ex rel. Baker v. Physician Partners of Am LLC; United States ex rel. Lupi v. Physician Partners of Am. LLC; and United States ex rel. Dookwah-Roberts v. Physician Partners of Am. LLC.
This result was accomplished by a team effort of the whistleblowers and the Attorney General’s COVID-19 Fraud Enforcement Task Force. The Task Force partners with agencies across government to try to catch and stop pandemic-related fraud, including the SBA. For more information on the DOJ’s efforts to fight pandemic related fraud, see https://www.justice.gov/coronavirus.
Hat’s off to the Agencies and the DOJ attorneys who handled these cases. The attorneys are DOJ Senior Trial Counsel, David W. Tyler, of the Civil Division; and, Assistant U.S. Attorney, Lindsay Saxe Griffin, for the Middle District of Florida.
Congratulations to one and all for the successful, quick resolution of this difficult and egregious case.