According to Principal Deputy Assistant Attorney General Brian M. Boynton, head of the Justice Department’s Civil Division, “Improperly billing federal health care programs depletes valuable government resources used to provide medical care to millions of Americans.” He emphasized the commitment to holding accountable healthcare providers who defraud taxpayers by knowingly submitting inflated claims.
Details of the Alleged Fraudulent Activities by Bluestone Physician Services
The settlement addresses allegations that between January 1, 2015, and December 31, 2019, Bluestone Physician Services knowingly submitted claims for two specific E&M codes that did not accurately reflect the level of service provided. These codes include:
- Domiciliary Rest Home Visit Code for Established Patients (99337): This code is intended for visits to patients in rest homes or similar domiciliary facilities.
- Chronic Care Management Code (99490): This code is for the management of chronic conditions requiring at least 20 minutes of clinical staff time directed by a physician or other qualified health professional per calendar month.
The government contended that Bluestone Physician Services billed these codes in situations where the services rendered did not justify the level of care claimed, effectively upcoding for financial gain. The federal government’s share of the settlement amounts to $13,842,482, with an additional $1,059,518 allocated to the states of Florida and Minnesota, reflecting the impact on state-administered healthcare programs.
U.S. Attorney Andrew M. Luger for the District of Minnesota stated, “Fraudulent billing undermines the integrity of government healthcare programs and diminishes legitimate services and resources for Minnesotans.” He warned that healthcare companies engaging in upcoding and unnecessary billing practices would face accountability for their misconduct.
Echoing this sentiment, U.S. Attorney Roger B. Handberg for the Middle District of Florida affirmed, “The submission of false claims to Medicare for chronic care services will not be tolerated in the Middle District of Florida.” He conveyed that this resolution serves as a clear message to healthcare providers within his district about the active investigation and prosecution of such fraudulent conduct.
Special Agent in Charge Mario M. Pinto of the Department of Health and Human Services, Office of Inspector General (HHS-OIG) Chicago Regional Office, highlighted the broader implications of healthcare fraud: “When health care providers submit false claims to taxpayer-funded federal health care programs, including inappropriately inflating claims to boost profits, the public’s trust in our nation’s medical providers and the integrity of federal health care programs are put at risk.” He reassured the public of ongoing collaboration with law enforcement partners to ensure accountability for those involved in such activities.
Corporate Integrity Agreement and Compliance Measures for Bluestone
In conjunction with the settlement, Bluestone Physician Services has committed to a five-year Corporate Integrity Agreement (CIA) with HHS-OIG. This agreement mandates Bluestone to establish and maintain a comprehensive compliance program. Key components of this program include:
- Implementing policies and procedures to ensure accurate and compliant billing practices.
- Conducting regular internal audits to monitor adherence to billing regulations.
- Providing training to staff on proper coding and billing procedures.
- Subjecting Medicare claims to review by an Independent Review Organization (IRO) to verify medical necessity, appropriate documentation, and correct coding.
This CIA is designed to ensure that Bluestone Physician Services adheres to the highest standards of ethical and legal conduct, preventing any recurrence of the alleged fraudulent activities.
The Role of the Whistleblower and the False Claims Act
The settlement originated from a qui tam or whistleblower lawsuit filed under the False Claims Act by Lisa Loscalzo, a former General Manager for Bluestone’s Florida market. The False Claims Act empowers private individuals to file actions on behalf of the United States when they have evidence of fraud against the government. Whistleblowers are entitled to a portion of any financial recovery resulting from these cases. Ms. Loscalzo will receive $2,831,380 as her share of the settlement.
The case, captioned U.S. ex rel. Loscalzo v. Bluestone Physician Services of Florida, Bluestone Physician Services, P.A., Bluestone National, LLC et al., underscores the critical role of whistleblowers in uncovering healthcare fraud and protecting taxpayer funds.
Collaborative Effort in Combating Healthcare Fraud
The resolution achieved in this case was the result of a coordinated effort involving multiple government agencies, demonstrating the government’s unified approach to combating healthcare fraud. The agencies involved include:
- Justice Department’s Civil Division, Commercial Litigation Branch, Fraud Section
- U.S. Attorneys’ Offices for the District of Minnesota and the Middle District of Florida
- Department of Health and Human Services, Office of Inspector General (HHS-OIG)
- Defense Criminal Investigative Service
- FBI
This collaborative investigation highlights the government’s strong emphasis on combating healthcare fraud, with the False Claims Act serving as a vital tool in these efforts. The public is encouraged to report any potential fraud, waste, abuse, and mismanagement to HHS at 800-HHS-TIPS (800-447-8477).
The Department of Justice and its partners are committed to ensuring the integrity of federal healthcare programs and safeguarding taxpayer resources from fraudulent activities perpetrated by healthcare providers.
It is important to note that the claims resolved by this settlement are allegations only, and there has been no determination of liability.
