ATLANTA — James Ellner, MD, and his Woodstock, Ga. pain management practice, Georgia Pain Management, PC, and his outpatient surgical center, Samson Pain Center, PC, have agreed to pay $625,000 to resolve allegations that they violated the False Claims Act (FCA). by filing improper claims with the Medicare and TRICARE programs for assessment and administration services and medically unnecessary urine drug testing.
“The federal government expects physicians and their practices to properly bill Medicare and TRICARE for the services they provide,” said US Attorney Ryan K. Buchanan. “The Justice Department will work diligently to hold health care providers accountable when they break the rules and overstate federal health programs.”
“Health care abuse like this undermines patients’ trust in the health care system,” said Keri Farley, the FBI’s Atlanta special agent in charge. “Government-subsidized programs like Medicare help protect the healthcare needs of deserving Americans, and the FBI is committed to working with our partners to prevent people from illegally benefiting from them.”
“When providers make improper claims, they compromise the integrity of tax-funded health programs and deprive intended recipients of these valuable resources,” said Tamala Miles, special officer in charge, Department of Health and Human Services, Office of Inspector General (HHS-OIG). “HHS-OIG is committed to protecting federal healthcare programs from fraudulent and wasteful practices on the part of providers.”
The FCA is a federal law that imposes civil liability on any person or entity who makes, or causes to be made, a false payment claim to the federal government or its agents. It awards treble damages (that is, three times the damage caused by the false claims) and a civil penalty of between $12,537 and $25,076 per false claim. The FCA is the primary agency of the United States Attorney’s Office of Civil Affairs in combating fraud, waste and abuse under federal programs, including but not limited to Medicare and TRICARE.
The United States alleges that between May 1, 2015 and December 31, 2019, James Ellner and Georgia Pain Management, PC (Georgia Pain) made false claims for non-reimbursable evaluation and management (E&M) benefits in the Medicare and TRICARE programs. have claimed under federal health programs. Medicare generally prohibits healthcare providers from separately billing for E&M services performed on the same day as another medical procedure, unless the E&M services are significant, separately identifiable, and go beyond the usual preoperative and postoperative care related to the medical intervention. If an E&M service meets these criteria, the provider can use a billing code called “Modifier 25” to bill for the essential and separately identifiable E&M services. In this case, the United States alleges that Georgia used Pain Modifier 25 to improperly unbundle routine E&M services that could not be billed separately from other minor surgical procedures performed on the same day; As a result, Georgia Pain requested a refund from Medicare and TRICARE, but was not due.
The United States also alleges that Ellner and Georgia Pain entered into an anti-kickback statute-violating agreement whereby a reference lab paid the salary of a person who acted as Georgia Pain’s freelancer in return for Ellner’s referral urine drug tests – many of which were medically unnecessary.
The civil settlement resolves a lawsuit filed by a former Georgia Pain employee in the US District Court for the Northern District of Georgia under the FCA’s qui tam or whistleblower rules. United States ex rel. Amy Tyson v Georgia Pain Management, PC, Samson Pain Center, PC, and James Ellner, MD, Civil Action 1:18-cv-5520. Under the FCA, individuals can bring false claims on behalf of the United States and participate in government recoveries. The whistleblower will receive $118,000 from the settlement.
The civil settlement was reached by Assistant US Attorney Mellori Lumpkin-Dawson. The claims resolved by the Settlement are allegations only and no determination of liability has been made.
For more information, please contact the US Attorney’s Office of Public Affairs at USAGAN.PressEmail@usdoj.gov or (404) 581-6016. The web address of the US Attorney’s Office for the Northern District of Georgia is http://www.justice.gov/usao-ndga.