Medicare Compliance & Reimbursement

Caution: The 2023 FCA settlement numbers may shock you.

Per usual, the feds are off and running in 2024 with several million dollar settlements — many targeting clinicians.

Backtrack: Though 2024 is looking like it’s going to be a banner year for Medicare enforcement, the 2023 statistics show last year was one for the ages, according to the Department of Justice (DOJ). For the fiscal year 2024, which ended on Sept. 30, 2023, False Claims Act (FCA) settlements surpassed $2.68 billion, according to a DOJ release on Feb. 22. In addition, “the government and whistleblowers were party to 543 settlements and judgments, the highest number of settlements and judgments in a single year,” DOJ crows.

Healthcare-related fraud accounted for more than $1.8 billion of that staggering amount and 348 of the qui tam cases, according to DOJ statistics. Find the DOJ release on the 2023 FCA numbers at www.justice.gov/opa/pr/false-claims-act-settlements-and-judgments-exceed-268-billion-fiscal-year-2023.

Here’s a look at what’s been on the feds’ February fraud enforcement radar.

In California: A physician could face up to 10 years in prison for fraudulently certifying that Medicare patients needed hospice services when they didn’t. Between October 2014 and March 2016, Dr. John Thropay worked with a number of hospices in and around Van Nuys, including Blue Sky Hospice Inc. During his tenure, he “fraudulently certified Medicare patients of Blue Sky as having terminal illnesses that the patients did not have so that Blue Sky Hospice could bill Medicare for hospice services,” DOJ notes in a release.

Thropay, who fraudulently billed Medicare for the hospice services at upward of $2.8 million, was convicted by a jury and will be sentenced on May 28. The maximum sentence for his conviction is 10 years. Read more about the case details at www.justice.gov/opa/pr/doctor-convicted-28m-medicare-fraud-scheme.

In New York: On Feb. 22, Queens-based physician Alexander Baldonado was indicted by a grand jury for “a health care fraud and illegal kickback scheme that involved the submission of over $20.7 million in false and fraudulent claims to Medicare for laboratory tests, including cancer genetic tests,” explains DOJ in a release.

Baldonado also allegedly participated in a COVID-19 testing scheme as well as a cancer testing scam. He ordered “expensive and medically unnecessary cancer genetic tests that patients did not request, that were not used in the patient’s treatment, and for which the patients rarely received the results,” according to DOJ. A trial has not been set at this time.

Find the case specifics at www.justice.gov/opa/pr/medical-doctor-charged-207m-health-care-fraud-and-illegal-kickback-schemes.

In New Jersey: Ramsey-based doctor Arun Sehgal agreed to pay the feds $700,000 to resolve FCA violations that allegedly occurred between Jan. 1, 2017 and June 1, 2022. Sehgal via his practice, Preventive & Diagnostic Medical Center P.A., was guilty of upcoding physician services and billing for more services than he could perform in one day; he also submitted claims for services he never provided.

Sehgal and his practice “knowingly submitted claims to Medicare for services that Sehgal did not provide to patients by regularly billing for impossible days,” DOJ explains. “An impossible day occurs when a physician purports to provide such a high volume of services or procedures in one day that there is no way the physician reasonably could have performed them all.” In one example, DOJ shows that Sehgal billed Medicare for 43 hours on March 2, 2018 — an impossible feat.

Review the resolution details at www.justice.gov/usao-nj/pr/ doctor-pay-nearly-700000-resolve-false-claims-act-allegations.