This browser is not actively supported anymore. For the best passle experience, we strongly recommend you upgrade your browser.
Welcome to Reed Smith's viewpoints — timely commentary from our lawyers on topics relevant to your business and wider industry. Browse to see the latest news and subscribe to receive updates on topics that matter to you, directly to your mailbox.
| 1 minute read

An important compliance lesson from a new DOJ false claims act settlement agreement

The office of the United States Attorney for the Eastern District of New York has just announced that the Department of Justice has entered into a settlement agreement with New York Presbyterian Hospital (NYPH) to resolve Federal False Claims Act (FCA) allegations. NYPH has agreed to pay $801,000 to resolve claims that two radiation oncology practices affiliated with the improperly billed Medicare, Medicaid and TRICARE for images used in image guided radiation therapy treatments (IGRT) provided to cancer patients during the years 2012 and 2018. IGRT uses imaging technologies such as PET, MRI, and CT to deliver radiation doses to cancer patients more accurately and safely in order to guide the precise delivery of radiation to cancer cells. 

At the core of the FCA allegations, the government alleged that Medicare was billed for images utilized in IGRT when such images were either not reviewed, or were not timely reviewed, and therefore were not reasonable and necessary.  If the images had been reviewed, there should have been documentation of that work.

This settlement illustrates the fundamental need for physicians: (i) to fully perform the work expected to order to be paid for the billed service and (ii) to document that they have done the work for which they ask for Medicare to reimburse.  Exposure to fraud and abuse claims arises when there is not sufficient documentation that the services billed and paid for were fully performed. FCA liability flows from submitting claims for reimbursement for federal program payments via Form CMS-1500 when the billing physician certifies that he or she furnished the professional services.  Specifically, the language on the 1500 form requires a physician to certify that the services were “personally furnished by me.”  It is prudent -– actually necessary -- to document that the physician work expected to be performed has in fact been done.

A good compliance lesson for all.



Further, the investigation found that initial consultation sessions at RTA were in some instances billed at a higher coding level than appropriate.


false claims act, radiation oncology, documentation, health care & life sciences