The University of Rochester's Medical Center (URMC) has agreed to reimburse both the state and federal governments the $113,722.10 that they are alleged to have illegally pocketed. URMC is alleged to have violated both the New York False Claims Act as well as federal law when it improperly used a billing code in filing claims through its Flaum Eye Institute.
In this instance, URMC is alleged to have improperly used the billing modifier 25. Authorities state that the use of this code can result in two independent charges for services, for example, an evaluation and procedure, even though they happened on the same day.
This is exactly the kind of activity that whistleblowers can prevent through the False Claims Act.
In URMC's particular case, it's argued that they used this modifier to bill for intravitreal injections, a type of injection made into the eye despite the fact that medical records didn't reflect that patients had received any additional care aside from the injection itself.
Officials from both the United States and New York State Attorney's offices reported that the error resulted in the upstate university receiving a number of both Medicaid and Medicare payments it otherwise would not have. In their joint statement of the repayment, the prosecutors' offices highlighted how a whistleblower who worked at URMC first discovered the error and filed a lawsuit in the case.
For its part, URMC issued a public statement highlighting that their staff discovered errors in the way that they billed for certain categories of ophthalmologist care. They argue that they were proactive in reporting the oversight themselves prior to any litigation commencing in the case.
The state attorney's office commended URMC for its self-reporting of its indiscretions. In doing so, they said that it takes parties coming forward and admitting fault and reimbursing misappropriated funds in cases like this to adequately protect the integrity of the Medicaid system. This case marks the third time a whistleblower at the University of Rochester has come forward in the past three years.
He also commended the whistleblower in this case for having come forward and reported her employer's misappropriation of funds. In this case, she stands to make millions of dollars awarded by both federal and state governments to those who step forward and report fraud.
If you have witnessed illegal activity by your employer or manage a business that has been accused of wrongdoing, you may benefit from discussing your legal matter with an experienced New York business litigation attorney.
Source: Democrat & Chronicle, "UR to pay more than $100K to settle false claims lawsuit," June 13, 2017