COLUMBIA, S.C. (WCSC) - The state’s largest urgent care provider and its management company have agreed to settle allegations of healthcare fraud, according to the U.S. Attorney for South Carolina.
Doctors Care, UCI and UCI Medical Affiliates, Inc. will pay $22.5 million to resolve the civil allegations made by a whistleblower complaint, according for Acting U.S. Attorney for South Carolina Rhett DeHart.
The complaint accused the companies of falsely certifying that certain urgent care visits were performed by providers who were credentialed to bill Medicaid, Medicare, and TRICARE for medical services. But the complaint stated the services were actually performed by non-credentialed providers.
Federal health insurance companies require physicians and midlevel providers to apply for and receive billing credentials that serve as approval to bill any services to the insurer, according to a release from DeHart’s office.
Providers are obligated to renew these billing credentials periodically and must obtain new credentials with new employment.
The complaint alleged that as early as 2013 and continuing to 2018, UCI was unable to secure and maintain necessary billing credentials for most Doctors Care providers. It also claimed UCI knew that federal insurance programs would deny claims submitted with the billing number of a provider who had not yet received their billing credentials, then allegedly submitted the claims falsely, “linking” the uncredentialed rendering providers to credentialed billing providers in order to get the claims paid.
“With each ‘linked’ bill, it is alleged that UCI knowingly submitted a false claim for payment,” the release states.
DeHart said evidence obtained in support of the allegations includes emails memorializing UCI’s “linking” scheme and well-organized “cheat sheets,” as employees called them, which UCI used to keep track of properly-credentialed billing providers whose names could be substituted on uncredentialed providers’ bills.
The “billing credentials” at issue in this case are distinct from a provider’s degree or license to practice medicine, the release states.
There is no evidence in this case that any Doctors Care provider lacked a medical license or that patient care was compromised due to the conduct at issue, the release states.
“When healthcare companies do business with the federal government, they must follow the rules like everyone else,” DeHart said. “All companies with this distinction – regardless of size – should honor their commitment to provide competent care to the full letter of the law. Our office will continue to protect tax dollars and ensure the rule of law is followed.”
“Taxpayers and Medicare patients rightly expect medical providers to be properly credentialed before billing for their services,” Department of Health and Human Services Special Agent Derrick Jackson said. “Working with our law enforcement partners, we will continue protecting Federal healthcare programs.”
“The results of this investigation exemplify the commitment of the United States Department of Defense Criminal Investigative Service and its law enforcement partners to root out fraud and corruption involving unscrupulous companies that undermine the integrity of the Department of Defense,” DCIS Mid-Atlantic Field Office Special Agent in Charge Christopher Dillard said. “This case should serve as a stark warning to those who attempt to exploit Department of Defense resources for personal gain.”
The settlement of $22.5 million is the result of over three years of investigation, led by the United States Attorney’s Office in coordination with the HHS-OIG and DCIS.
Upon receiving the first investigative subpoena in early 2018, management for UCI and Doctors Care acted promptly to investigate and stop the conduct subject to this settlement, the release stated.
In addition to the monetary settlement, UCI and Doctors Care also entered into a Corporate Integrity Agreement with the Office of Inspector General, DeHart said. The agreement requires that for the next five years UCI must retain an Independent Review Organization to perform a claims review in accordance with the specific requirements of the Corporate Integrity Agreement, and it requires that UCI routinely be monitored by the Office of Inspector General.