Cash Rewards Available for Information about Clinics, Radiology Practices and Hospitals Improperly Performing or Reading Obstetric Ultrasounds
State and federal rules regarding obstetrical ultrasounds may vary a bit but there are two overarching themes.
Obstetric ultrasounds generally require direct supervision by the treating provider. The operative terms are “direct supervision” and “treating provider.”
The term “direct supervision” is defined by state law but generally means being present in the room when the services are performed.
For example, Florida defines direct supervision in their Medicaid administrative regulations as follows:
‘Supervision’ means directing and being fully legally responsible for the actions of another person. ‘Direct supervision’ means face-to face supervision during the time the services are being furnished. ‘Personal supervision’ means that the services are furnished while the supervising practitioner is in the building and that the supervising practitioner is in the building and the supervising practitioner signs and dates the medical records (chart) within 24 hours of the provision of the service.
The rules also often require obstetric ultrasounds be under the direct supervision of the treating provider.
Assuming a patient is a Medicare or Medicaid recipient, obstetric ultrasounds aren’t eligible for reimbursement if the supervision rules are not followed.
Medicare Fraud Ultrasound Case Study
In April 2018, three former physicians from a central Florida obstetrics practice filed a whistleblower lawsuit claiming the company was allowing unqualified people who were not the treating providers to perform obstetric ultrasounds.
George Chisholm, Anthony Perrin and David Teitelbaum are all Florida licensed physicians. For several months in 2015 they worked at an Orlando area healthcare company practicing in the fields of obstetrics, gynecology and prenatal services.
Instead of being read by radiologists or obstetrics specialists, the three doctors say the ultrasounds were both read, and the reports signed, by unqualified providers. According to them, the practice allowed the obstetric ultrasounds to be reviewed and signed by midwives or ultrasound technicians.
After learning of the problem, the director of nursing allegedly asked one of the doctors to sign the reports. He refused and said doing so was still illegal. According to him, there were at least 50 reports signed by a midwife as a “reading physician.” He says that he correctly refused and reminded the clinic that improper ultrasound procedures may violate both Medicaid rules and state law.
In his words,
First, [the midwife] is not a physician. You have to be licensed to sign a report as a physician. Alleging otherwise is fraud and against the law.
Jessica [the midwife] is totally unqualified to ready any ultrasounds. She neither has the training nor the Board Certification to read ultrasounds – that’s also a fraud.
The fact that we are billing for these ultrasounds with her names on the reports, as the reading physician is fraud, and we will be legally liable. If audited, and we are found to have been paid on even one claim with her name on the scan, we will be investigated, fined and likely lose some of our insurance networks.
Furthermore she is not eve credentialed on any, if not all of the insurance plans of the Pts for which she has signed off on their ultrasound reports.
If I or any of the Obstetricians countersigns Jessica signature, we are not only condoning her actions, but we will be committing fraud as well, since there would be no way to dispute the fact that these reports were first “Read” by her and signed by her… This is a serious matter, and I will not put my license at risk for this, or any midwife, who exercises poor judgement, and refuses to seek the advice of any of the supervising Obstetricians.
Less than three weeks later after all three doctors refused to sign the reports, all were allegedly terminated.
The three doctors filed a whistleblower lawsuit on April 10, 2018.
[Update December 2018: We have redacted the name of the practice as the claims are being dismissed. We understand that a separate employment action continues.]
Whistleblower Rewards and Medicare Fraud Lawsuits
Why file a whistleblower lawsuit? Filing an employment claim for retaliation (whistleblower retaliation is highly illegal) may get your job back or at least double lost wages. But it doesn’t stop the fraud.
A Civil War era law, the False Claims Act, allows whistleblowers with inside information to seek a reward. Thousands of Medicare fraud complaints are made to government hotline numbers each year. Only a tiny percentage are investigated. The Centers for Medicare and Medicaid Services just don’t have enough people to investigate every claim.
File a False Claims Act lawsuit, however, and your case goes to the top of the pile. Even better, you can earn a large cash reward for your information and be better positioned for an illegal retaliation claim.
Under the Act, whistleblowers can receive between 15% and 30% of whatever the government collects from the wrongdoers. With fines of over $20,000 per false bill submitted ($10, 000 in 2015 when the doctors worked at True Health), the penalties can quickly add up. Just 50 mis-signed obstetric ultrasounds equate to over $500,000 in penalties.
Unfortunately, we were not surprised to see the doctors lost their jobs after complaining that ultrasound practices were illegal. Very often companies will try to silence whistleblowers or banish them to a position where they can’t cause any trouble. These doctors say they paid the ultimate price… they were fired.
Whistleblowers should be rewarded for stepping forward and never punished. That’s why the False Claims Act contains both cash rewards and anti-retaliation provisions.
How Many Other Improper Obstetric Ultrasound and Other Schemes Are Out There?
We suspect there are many clinics, hospitals and standalone MRI / X-Ray clinics that are falsely billing or performing these procedures. Not only are taxpayers the victims of these schemes (Medicare and Medicaid are financed through tax dollars), the scheme is dangerous.
Patients expect a high level of care. We certainly need ultrasound technicians and midwifes too. Both have an important role in our healthcare system. Congress and the state legislatures put minimum training and supervision requirements into the law for a reason, however. Unless a state law says otherwise, technicians shouldn’t be performing procedures that require a physician or the direct supervision of a physician.
We have seen a wide variety of fraud involving radiology and related fields. That some providers are forcing unqualified staff to review obstetric ultrasounds is unfortunately not surprising.
In 2016, the United States Supreme Court said violations must be material before a reward can be paid under the False Claims Act. Depending on the size of the facility and patient volume, fifty bad ultrasounds may not be enough to prove a pattern and practice of fraud. But it certainly a close, close call and retaliation is always illegal.
Every Medicare fraud whistleblower case is unique, and each have their own set of merits. Four things remain fairly constant, however.
First, you must file a sealed lawsuit in court to even be eligible for a reward. Calling a toll free hotline is a great way to remain anonymous but won’t get you a reward and is often ineffective.
Second, you must generally be the first to file – that means DON’T WAIT!
Third, you must have inside information.
And finally, the fraud must involve government healthcare dollars. (There are private insurance whistleblower rewards available in California and Illinois.)
Ready to learn more? Visit our healthcare fraud whistleblower page. Ready to see if you have a case? Contact us online, by email or by phone (414) 704-6731. All inquiries without fee or obligation and always confidential.