Whistleblowers expose unnecessary medical testing and physician payments, results in $24 million settlement

Apr 12

A Florida healthcare company has agreed to pay $24.5 million after employees exposed that it was allegedly billing the federal government for unnecessary medical testing and services and illegally paying its physician employees.

Physician Partners of America LLC of Tampa, Fla., agreed to settle allegations that it violated the federal False Claims Act, the U.S. Justice Department said April 12.

Whistleblowers who expose healthcare fraud are helping to ensure the financial health of the nation’s healthcare system, said Scott Williams, CEO of Ethic Alliance.

“US healthcare spending reached $4.1 trillion in 2020. Whistleblowers play a critical role in helping police the industry. It’s literally impossible for any central authority to police an industry that large,” said Williams.

Ethic Alliance is a for-profit corporation and law firm whose purpose is to empower, educate and protect whistleblowers, ensuring they receive the protection they need and the rewards they are entitled to under US law (the US government will typically reward whistleblowers 10%-30% of the amount recovered or sanctioned under various whistleblower laws), generating profits for investors while reducing corruption, fraud, theft, lying and cheating in our society.

Ethic Alliance protects whistleblowers through a secure, encrypted reporting and messaging platform, attaching the strong legal protection of attorney-client privilege from the moment a report is filed with us, and access to a network of specialty attorneys that have made careers protecting and supporting whistleblowers, and working with the US government to win whistleblower lawsuits.

The Physician Partners of America case was exposed by current or former employees of PPOA, including Donald Haight, Dawn Baker, Dr. Harold Cho, Dr. Venus Dookwah-Roberts and Dr. Michael Lupi, who filed claims against the company under the “qui tam” or whistleblower provisions of the False Claims Act, according to the Justice Department. The law allows a private party to file an action on behalf of the United States and receive a portion of any recovery.

The United States alleged that PPOA caused the submission of claims for medically unnecessary urine drug testing (UDT), 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. PPOA’s affiliated toxicology lab then billed federal healthcare programs for the highest-level UDT. In addition, PPOA incentivized its physician employees to order presumptive UDT by paying them 40% of the profits from such testing in violation of the 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, unless an exception applies.

The United States further alleged that PPOA required patients to submit to genetic and psychological testing before the patients were seen by physicians, without making any determination as to whether the testing was reasonable and necessary, and then billed federal healthcare programs for the tests.

The United States further alleged that when Florida suspended all non-emergency medical procedures to reduce transmission of COVID-19 in March 2020, PPOA sought to compensate for lost revenue by requiring its physician employees to schedule unnecessary evaluation and management (E/M) appointments with patients every 14 days, instead of every month as had been PPOA’s prior practice. PPOA then instructed its physicians to bill these E/M visits using inappropriate high-level procedure codes. Moreover, the United States alleged that at the same time PPOA was engaged in this unlawful overbilling, PPOA falsely represented to the SBA that it was not engaged in unlawful activity in order to obtain a $5.9 million loan through the Paycheck Protection Program, which was intended to help individuals and businesses hurt by the Covid-19 pandemic.

Photo by Hush Naidoo Jade Photography on Unsplash

health care fraudqui tamwhistleblowers

David Allison