U.S. ex rel. Sharp v. E. Okla. Orthopedic Ctr. (Summary)

QUI TAM/FALSE CLAIMS ACT

U.S. ex rel. Sharp v. E. Okla. Orthopedic Ctr., No. 05-CV-572-TCK-TLW (N.D. Okla. Oct. 29, 2013)  

The U.S. District Court for the Northern District of Oklahoma granted in part and denied in part an orthopedic medical practice’s motion for summary judgment against a terminated front desk supervisor who alleged violations of the False Claims Act (“FCA”) by the practice through upcoding preoperative examinations, miscoding of follow-up visits, waiving Medicare coinsurance and deductibles for certain patients, and billing patient accounts involving worker’s compensation and liability claims to Medicare instead of primary insurance first, resulting in violations of the Medicare Secondary Payer (“MSP”) rules.

The court primarily held that there was insufficient evidence to prove the required falsity and knowledge of these violations.  The front desk supervisor alleged that claim forms for follow-up visits misstated services provided by a specific physician’s usage of the diagnosis code for degenerative joint disease for follow-up visits.  The court found that the degenerative joint disease was the underlying reason why the patients required the procedure done by the physician and there was nothing false about the physician’s coding the visits that way.

With regard to incorrectly classifying a patient as an insurance only patient and not collecting coinsurance deductibles for his visits, the court found that although the medical center did, in fact, fail to disclose that it routinely waived the coinsurance and deductibles for the patient, this was a mere oversight in failing to change the status of the patient.

The argument that the medical center billed patient accounts involving worker’s compensation and liability claims to Medicare in violation of MSP rules failed because, given the confusion regarding the MSP regulations at the time, the medical center’s attempts at compliance were sufficient.

The court found that the front desk supervisor could proceed on the question of retaliatory intent for her discharge as the medical center not only had notice of her external whistleblowing activities but also proffered an implausible reason for her discharge.