South Carolina-based Doctors Care and UCI Medical Affiliates of South Carolina will pay $22.5 million to resolve Medicare fraud allegations. The alleged misconduct was exposed in a False Claims Act lawsuit filed by two whistleblowers who used to work at UCI, a medical biller and a health care management specialist. The whistleblowers will share a $5.4 million award for their efforts in uncovering fraud.
UCI manages Doctors Care, an urgent-care chain headquartered in Columbia. The two companies allegedly conspired to defraud Medicare, Medicaid, and Tricare.
With over 50 locations throughout South Carolina, Doctors Care is one of the largest urgent care providers in the state, servicing a large number of government healthcare program beneficiaries.
Doctors Care’s locations are informally known as “quick clinics;” they provide an alternative to rushing to a hospital emergency room.
According to prosecutors, between 2013 and 2018, the defendants submitted hundreds of false claims for payment to the government. The two companies allegedly billed the government for urgent care visits that were not eligible for reimbursement.
To trigger Medicare reimbursements, treating doctors must hold certain credentials. The defendants allegedly billed Medicare, Medicaid, and Tricare for urgent care provided by non-credentialed physicians, substituting the names of credentialed ones in claims for payment.
In one case documented in the lawsuit, a patient was treated by a doctor’s assistant at a Doctors Care clinic. Although there was no doctor credentialed by Medicare on-site, the defendants submitted a claim signed by a credentialed doctor to the government. As a result, Doctors Care received a $102.20 payment from Medicare.
As the defendants received millions of dollars from the government programs, Medicare and Medicaid beneficiaries systematically received care from doctors without the required billing credentials.
The government has implemented billing credentials to make sure that Medicare beneficiaries receive the highest level of care. According to the lawsuit, “The enrollment and credentialing process can often be costly in terms of time, resources, and administrative overhead. (But it) is designed to protect Medicare beneficiaries from receiving care or services from unqualified providers, protect Medicare beneficiaries from providers whose licenses are limited or restricted, and protect Medicare beneficiaries from providers who are excluded from the Medicare program and other Federal Healthcare Programs.”
Billions of taxpayer dollars are lost to healthcare fraud every year. Individuals with information about Medicaid and Medicare fraud can file a lawsuit under the False Claims Act. If their complaint leads to a favorable verdict or settlement, the whistleblowers can receive up to 30 percent of the government’s recoveries.