James Ellner, M.D., and his Woodstock, Georgia pain management practice, Georgia Pain Management, P.C., and ambulatory surgical center, Samson Pain Center, P.C, agreed to pay $625,000 to resolve allegations that they violated the False Claims Act (FCA) by submitting improper claims to the Medicare and TRICARE programs for evaluation and management services and medically unnecessary urine drug screening tests.
“The federal government expects that physicians and their practices will properly bill Medicare and TRICARE for services they provide,” said U.S. Attorney Ryan K. Buchanan. “The Department of Justice will work diligently to hold healthcare providers accountable when they break the rules and overbill federal healthcare programs.”
“Health care fraud abuse like this case erodes the trust patients have in the health care system,” said Keri Farley, Special Agent in Charge of FBI Atlanta. “Government subsidized programs like Medicare help protect the healthcare needs of deserving Americans and the FBI is determined to work with our partners to prevent people from illegally profiting off of them.”
“When providers submit improper claims, they threaten the integrity of taxpayer-funded health care programs and take those valuable resources away from their intended recipients,” said Tamala Miles, Special Agent in Charge at the Department of Health and Human Services, Office of Inspector General (HHS-OIG). “HHS-OIG is committed to protecting federal health care programs from fraudulent and wasteful practices at the hands of providers.”
The FCA is a federal law that imposes civil liability on any persons or entities who submit, or cause to be submitted, false claims for payment on the federal government or its contractors. It imposes treble damages (that is, three times the loss caused by the false claims) and a civil penalty between $12,537 to $25,076 per false claim. The FCA is the primary authority used by the Civil Division of the United States Attorney’s Office to redress fraud, waste, and abuse within 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, P.C. (Georgia Pain) submitted false claims to the Medicare and TRICARE programs for evaluation and management (E&M) services that were not reimbursable under federal health care programs. Medicare generally prohibits healthcare providers from separately billing for E&M services provided on the same day as another medical procedure, unless the E&M services are significant, separately identifiable, and above and beyond the usual preoperative and postoperative care associated with the medical procedure. If an E&M service satisfies these criteria, the provider can use a billing code known as “Modifier 25” to bill for the significant and separately identifiable E&M services. In this case, the United States alleges that Georgia Pain used Modifier 25 to improperly unbundle routine E&M services that were not separately billable from other minor surgical procedures performed on the same day; and as a result, Georgia Pain claimed reimbursement from Medicare and TRICARE that it was not due.
The United States also alleges that Ellner and Georgia Pain entered into an arrangement that violated the Anti-Kickback Statute, whereby a reference laboratory paid the salary of an individual who functioned as a free employee of Georgia Pain in exchange for Ellner’s referral of urine drug tests – many of which were medically unnecessary.
The civil settlement resolves a lawsuit filed in the U.S. District Court for the Northern District of Georgia by a former employee for Georgia Pain, under the qui tam, or whistleblower provisions, of the FCA. United States ex rel. Amy Tyson v. Georgia Pain Management, P.C., Samson Pain Center, P.C., and James Ellner, M.D., Civil Action 1:18-cv-5520. Under the FCA, private citizens may bring suit for false claims on behalf of the United States and share in any recovery obtained by the government. The whistleblower will receive $118,000 from the settlement.
The civil settlement was reached by Assistant U.S. Attorney Mellori Lumpkin-Dawson. The claims resolved by the settlement are allegations only, and there has been no determination of liability.