Seeing Dollar Signs: U.S. Settles with Ophthalmologist for $1.4 Million to Resolve FCA Claims

Last week, the United States settled with a Baltimore ophthalmologist for alleged violations of the False Claims Act (“FCA”). Pursuant to the settlement, the ophthalmologist, Dr. John Arthur Kiely, agreed to pay $1.4 million to the government and to be excluded from participation in Medicare and Medicaid for 20 years. Generally, the FCA imposes civil liability, allowing the government to recover up to treble damages, for fraudulent claims made to the government for proceeds from government programs, such as Medicare and Medicaid.

The government’s allegations of fraud arose in connection with Dr. Kiely’s provision of a number of procedures at Bon Secours Hospital in Baltimore from 2002 to 2009. According to a Department of Justice (“DOJ”) press release, Dr. Kiely performed Argon Laser Trabeculoplasties (“ALTs”) and Laser Peripheral Iridotomies (“LPIs”), both treatments for glaucoma that were not medically reasonable or necessary. While there is no hard and fast definition of “medically reasonable and necessary,” generally, the provision of services not supported by or not warranted by a patient’s diagnosis are not considered medically reasonable or necessary. Services must be medically reasonable and necessary to be reimbursed by Medicare and Medicaid. In Dr. Kiely’s case, the government alleged that Dr. Kiely performed medically unnecessary ALTs and LPIs for his financial benefit, rather than in the best interest of his patients. Dr. Kiely did not admit any wrongdoing in connection with the settlement.

As mentioned, part of the settlement requires that Dr. Kiely be excluded from participating in Medicare and Medicaid for 20 years. An exclusion means that no payment from either program will be made for any service that Dr. Kiely furnishes, orders, or prescribes for the next 20 years. This exclusion applies even if Bon Secours Hospital, not Dr. Kiely, submits the claim for reimbursement to the government. In announcing the settlement, Nick DiGiulio, Special Agent in Charge for the Inspector General’s Office of the United States Department of Health and Human Services, stated that the government “rel[ies] on physicians to perform only needed services and to bill appropriately.”

The Health Law Gurus™ will continue to follow fraud and abuse issues arising under Federal health care programs.

To view the DOJ press release, click here.

DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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