In The News

Healthcare Provider Agrees to pay $2 Million to Settle False Claims Act Allegations

A diagnosis of cancer is possibly one of the worst things a patient can hear from his/her doctor. What can make a diagnosis such as this even worse is when health care providers trusted with helping patients along this serious journey act unethically. This is what the government says that one provider has done. Last month the Department of Justice announced that Biotheranostics Inc., a San Diego-based diagnostic laboratory, has agreed to pay $2 million to resolve allegations that it submitted false claims to Medicare for Breast Cancer Index (BCI) tests that were not necessary for the diagnosis or treatment of breast cancer. “Health care providers are responsible for ensuring that the services they provide to Medicare beneficiaries are both reasonable and necessary,” said Acting Assistant Attorney General Chad A. Readler of the Justice Department’s Civil Division. “Laboratories that knowingly submit claims for non-reimbursable services will be held accountable.”

By law, Medicare is only responsible for the cost of laboratory tests that are “reasonable and necessary for the diagnosis or treatment of a patient’s illness or injury.” In this case, the government alleged that Biotheranostics knowingly performed BCI tests for breast cancer patients it knew had gone into remission for five years. Thus, the test was not medically necessary or reasonable based on clinical practice guidelines. In doing so, Biotheranostics is also alleged to have violated the False Claims Act by submitting claims to Medicare for these unnecessary procedures.

The False Claims Act is one tool the government has used to prosecute such cases. As part of the qui tam or whistleblower provisions of this act, private citizens are able to sue on behalf of the government and to retain the services of a false claims act lawyer. The government began to vigorously pursue whistleblower Medicare cases back during the previous administration resulting in billions of dollars being returned to government and state programs such as Medicare, Medicaid and TRICARE. (TRICARE is a health care program for uniformed service members and their families.)

“Fighting health care fraud will continue to be a priority of this office,” said United States Attorney Adam L. Braverman for the Southern District of California. “As this settlement demonstrates, we will vigorously investigate and hold responsible laboratories and other providers that choose to submit claims to federal health care programs for unauthorized or unnecessary services.”