U.S. ex rel. Armfield v. Gills (Summary)

FALSE CLAIMS ACT

U.S. ex rel. Armfield v. Gills, No. 8:07-CV-2374-T-27TBM (M.D. Fla. Jan. 30, 2013)

In this FCA case, the United States District Court for the Middle District of Florida denied a physician’s motion for summary judgment.  The government brought suit against the physician for claims fraudulently billed to Medicare.  The government alleged, over the course of a patient’s cataract surgery, the physician upcoded procedures and examinations so that Medicare would pay for them.

The district court denied summary judgment on claims that false codes and medically unnecessary procedures were used to defraud the government.  The court stated that the correctional procedure performed after the first cataract surgery was coded properly, but a dispute existed over whether the procedure was medically necessary.  The correctional procedure met the regulatory requirements of a minor surgery: it was performed in a “minor procedural room” and required topical anesthesia.  There was, however, an issue of fact over whether the procedure was to be considered a correction or was meant to be an alternative to corrective lenses.  Due to this issue of material fact, the district court denied summary judgment.

The district court also denied summary judgment of the claim that the decision to perform the second cataract surgery was falsely billed to Medicare.  The court stated that the differing opinions of the experts needed to be heard by a reasonable jury.  The physician’s expert argued that the final decision on the second surgery was a regulatory requirement.  The government’s expert argued that the second pre-surgery examination (which occurred prior to the surgery on the patient’s second eye) was unnecessary and that the examination performed before the first cataract surgery would have been sufficient.

The court stated that the fact that the physician submitted the claims based on the advice of a consultant was not controlling.  The district court believed that a reasonable jury could determine that the physician acted with disregard when submitting his Medicare claims.