MM Curator summary
The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.
[MM Curator Summary]: A device maker did a backdoor billing / kickback scheme with the help of some local DME providers.
RALEIGH, N.C. – United States Attorney Michael Easley announced today that Joint Active Systems, Inc. (JAS), a manufacturer of range-of-motion devices located in Effingham, Illinois, has agreed to pay $500,000 to settle civil claims under the Federal and North Carolina False Claims Acts concerning allegations that JAS caused submission of false claims to the North Carolina Medicaid program for certain durable medical equipment.
Specifically, the United States and the State of North Carolina alleged that from January 6, 2012 through January 29, 2021, JAS was unable to directly bill North Carolina Medicaid for its “EZ” range-of-motion devices because JAS did not meet North Carolina Medicaid requirements and/or lacked credentials necessary to do so. JAS allegedly bypassed those requirements—and its concomitant inability to bill North Carolina Medicaid directly—by entering into arrangements with local North Carolina orthotics and prosthetics providers to bill EZ devices on its behalf. JAS allegedly directed the local North Carolina orthotics and prosthetics providers to improperly submit claims for JAS EZ devices as orthotics using “L-Codes” under the Healthcare Common Procedure Coding System (“HCPCS”), thereby bypassing the medical necessity reviews and/or authorization processes that may have otherwise taken place. The Governments alleged that the JAS EZ devices did not qualify for reimbursement as “L-Code” orthotics under North Carolina Medicaid, and that the JAS EZ devices were not listed as reimbursable devices on the North Carolina Medicaid fee schedule. Indeed, JAS received an official coding verification from the Centers for Medicare and Medicaid Services that designated one of JAS’s EZ devices as an “E-Code” (durable medical equipment) device, not as an “L-Code” (orthotic) device. The Governments alleged that JAS nevertheless continued to use local North Carolina providers to bill its EZ devices as “L-Code” devices. In turn, JAS allegedly would pay the local orthotics and prosthetics providers by allowing them to retain a certain amount of the reimbursement.
“The Department of Justice is actively pursuing health care companies and medical device manufacturers who overcharge government healthcare programs,” said United States Attorney Michael Easley. “We cannot allow companies to bypass rules and regulations to enrich themselves, while depleting taxpayer funds set aside for legitimate patient care.”
“My office’s Medicaid Investigations Division will hold accountable Medical device manufacturers who drain resources from our government healthcare programs, no matter how elaborate and layered the scheme may be,” said North Carolina Attorney General Josh Stein.
The Federal and North Carolina False Claims Acts authorize the Governments to recover triple the money falsely obtained, plus substantial civil penalties for each false claim submitted.
It should be noted that the civil claims resolved by settlement here are allegations only, that there has been no judicial determination or admission of liability, and that JAS denies the allegations.
This matter was investigated by the United States Attorney’s Office for the Eastern District of North Carolina and the Medicaid Investigations Division of the North Carolina Attorney General’s Office (“MID”). Special Deputy Attorney General Matthew R. Petracca, who also serves as a Special Assistant United States Attorney, represented the United States and the State of North Carolina.
The United States Attorney’s Office for the Eastern District of North Carolina, in partnership with law enforcement agencies and state entities, investigates and prosecutes healthcare providers that defraud government programs, including Medicare and Medicaid, and abuse their patients. The Medicaid Investigations Division investigates and prosecutes healthcare providers that defraud the Medicaid program, patient abuse of Medicaid recipients, patient abuse of any patient in facilities that receive Medicaid funding, and misappropriation of any patients’ private funds in nursing homes that receive Medicaid funding. To report Medicare fraud or patient abuse in North Carolina, please visit the United States Department of Health and Human Services’ website at https://oig.hhs.gov/fraud/. To report Medicaid fraud or patient abuse in North Carolina, please call the MID at 919-881-2320.