Sioux City-Based Physician Group, Tri-State Specialists, LLP, Agrees to Pay Over $600,000 to Resolve False Claims Act Allegations | USAO-NDIA

Tri-State Specialists, LLP (Tri-State), has agreed to pay $612,501.44 to the United States, the State of Iowa and the State of South Dakota to resolve allegations that it allegedly violated the False Claims Act by charging Medicare, Medicaid, TRICARE, and the Federal Employees Health Benefits Program for medically unnecessary procedures and for procedures beyond those actually performed.

The government alleged that, from August 2014 to August 2019, Tri-State submitted false claims for payment to government health programs for surgeries and office visits performed by a plastic surgeon who was previously a partner of Tri-State. State. The government argued that the claims submitted during this period violated the False Claims Act in three ways. First, the government alleged that the surgeon performed cosmetic procedures not reimbursable by government health care programs, including panniculectomies and tummy tucks (also known as tummy tucks) and cosmetic breast reductions, which were falsely billed as procedures. medically necessary. Second, the government alleged that the surgeon had failed to provide sufficient services to warrant billing for high value muscle flap and adjacent tissue transfer surgeries. Third, the government alleged that the surgeon failed to provide sufficient services to charge for high-value office visits that require a full examination, complete history and detailed supporting documentation for patients requiring moderate medical decision-making. or very complex.

The United States alleged that Tri-State was liable for the surgeon’s actions both because the surgeon was an agent of Tri-State and because Tri-State had knowledge of the surgeon’s actions.

“Investigating and enforcing misrepresentation is critical to protecting government health programs on which millions of Americans depend. We will continue to vigorously investigate allegations of overcharging and medically unnecessary services in this district. said U.S. Attorney Sean Berry.

“We work tirelessly alongside our law enforcement partners to investigate allegations of misinvoicing and to ensure the proper use of US taxpayer dollars,” said Curt L. Muller, Agent Special Charge of the Office of Inspector General of the U.S. Department of Health and Human Services. . “Excessive claims on federal health care programs undermine the effectiveness of those programs and deprive those programs of essential resources.”

“As the investigative arm of the Office of Inspector General (DoD IG) of the Department of Defense, one of the primary missions of the Defense Criminal Investigative Service (DCIS) is to protect valuable cash taxpayers who fund programs like Tricare, the military’s health care system,” said Acting Special Agent in Charge Gregory P. Shilling of DCIS Southwest Field Office. “Today’s settlement Today is a testament to the determination of our officers and partners to investigate allegations of misrepresentation and protect taxpayer dollars.”

“The integrity of federal health care programs is at risk when providers submit false claims,” ​​said Amy K. Parker, Special Agent in Charge, Office of Personnel Management, Office of the Inspector General (OPM OIG) . “The OPM OIG is committed to working closely with our law enforcement partners to investigate allegations of fraud to protect taxpayer funds.”

This civil case arises out of an action brought under the whistleblower provisions of the False Claims Act. Pursuant to this law and the settlement agreement, the whistleblower will participate in the financial recovery of the United States.

The claims made against Tri-State are only allegations; there was no determination or admission of liability.

The case was handled by Assistant United States Attorneys Melissa A.

Carrington and Matthew K. Gillespie and the Iowa State Attorney General’s Office and were investigated by the US Department of Health and Human Services, Office of Inspector General; the United States Department of Defense Office of Inspector General, Defense Criminal Investigative Service; the United States Office of Personnel Management, Office of the Inspector General; and the State of Iowa Medicaid Fraud Control Unit.

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