Pediatric Practice Pays $65,378 to Settle Allegations Under the False Claims Act

May 27, 2010 - David B. Fein, United States Attorney for the District of Connecticut, today announced that MILFORD PEDIATRIC GROUP, P.C., a pediatric medical practice with a business address at 20 Commerce Park, Milford, Connecticut, has entered into a civil settlement agreement with the Government in which it will pay $65,378 to resolve allegations that it violated the False Claims Act.

U.S. Attorney Fein explained that the allegations against MILFORD PEDIATRIC involved improper billing of a “special services” code. When services such as office visits are provided on days when the office is normally closed or after a provider’s usual office hours, a provider is permitted to bill an add-on code and receive an extra payment, in addition to the payment for the underlying service. Between 2006 and 2009, the so-called “after hours” billing code (CPT code 99050) was defined as services provided “at times other than regularly scheduled office hours, or days when the office is normally closed (e.g. holidays, Saturday or Sunday).”

In 2006, the American Medical Association provided the following guidance as to when this add-on code could be properly billed: “A patient develops severe ear pain that is unresponsive to home treatment. Late Monday evening after the office is closed, the physician agrees by telephone to meet the patient in the office to provide treatment. CPT code 99050 is reported in addition to the basic service.” The American Academy of Pediatrics also issued guidance on this and other add-on codes in 2004: “the AMA further clarifies the use of these codes by indicating they cannot be used when the physician and staff ‘plan’ to be at the office ready and available to address patients who may require care, albeit previously unscheduled.”

The Government alleges that MILFORD PEDIATRIC GROUP routinely billed Medicaid for the special add-on code and received additional payments, above and beyond the usual payments for the services in question, when the practice was not closed, but instead was open for business and regularly scheduling patients for same day sick visits.

To resolve its liability under the False Claims Act, MILFORD PEDIATRIC GROUP will pay double damages, in the amount of $65,378, in order to reimburse the Medicaid program for conduct occurring between January 1, 2006 and March 31, 2009. The False Claims Act provides for treble damages and penalties of $5,500 to $11,000 per false claim submitted to the Government.

In entering into the civil settlement agreement, MILFORD PEDIATRIC GROUP did not admit liability.

This matter was investigated by the Federal Bureau of Investigation and the U.S. Department of Health and Human Services, Office of Inspector General. The case was prosecuted by Assistant United States Attorney Anne F. Thidemann, along with Auditor Kevin A. Saunders.

People who suspect health care fraud are encouraged to report it by calling 1-800-HHS-TIPS or the Health Care Fraud Task Force at (203) 785-9270.