San Diego-based Scripps Health, a health care system, has agreed to settle False Claims Act allegations for $1.5 million. According to the Department of Justice, Scripps Health violated the Act by billing Medicare and TRICARE for physical therapy services performed by un-enrolled therapists. A former employee blew the whistle on the unlawful billings against the two federal health programs, and she will receive a $225,000 reward in return for her service.
Medicare and TRICARE, the health insurance program provided to uniformed military service members and their dependents, only allow healthcare providers who are enrolled in the network to bill for services. Other services can be provided, but those services must be billed as "incident to" services provided by an enrolled provider. When an un-enrolled service provider wishes to bill as incident to an enrolled one, he or she must be directly supervised by the enrolled provider.
"These requirements help protect patients from unscrupulous or unqualified medical professionals," explains the acting assistant attorney general for the Justice Department's Civil Division.
According to the whistleblower's complaint and the Justice Department's allegations, Scripps Health billed Medicare and TRICARE for services provided by physical therapists who were neither enrolled providers nor directly supervised by an enrolled provider. This violated the programs' rules and allegedly resulted in false claims against the program.
"Patients rightly expect qualified medical providers, or at least professionals working under the supervision of authorized providers," said the special agent in charge for the Office of Inspector General of the U.S. Department of Health and Human Services. "As charged, these billing practices cheat patients, taxpayers, and the Medicare program."
Under the qui tam provisions of the False Claims Act, whistleblowers can obtain a reward. That reward is a percentage of the false, fraudulent, wasteful or abusive claims against government programs that they uncover. In this case, the whistleblower received 15 percent of the total settlement. In some cases, whistleblowers may be entitled to as much as 30 percent of the false claims they uncover.