Georgia Hospital Pays $2.5 Million for Ambulance Billing Fraud

Federal prosecutors announced a multi-million-dollar settlement today with The Medical Center of Central Georgia and Navicent Health (“Navicent”) over alleged False Claims Act (“FCA”) violations. Under the terms of the settlement, Navicent has agreed to pay to the United States and the State of Georgia $2,549,742 to resolve allegations that it violated the False Claims Act and the Georgia False Medicaid Claims Act by submitting bills for ambulance transports that were inflated or medically unnecessary, and were often both.

The settlement signals the completion of a two-year government inquiry into Navicent’s ambulance billing practices. The investigation was initiated when an employee-turned-whistleblower “tipped-off” government authorities about the ambulance billing fraud. Information provided by Andre Valentine, the whistleblower, and fruits of the government investigation revealed two suspected schemes through which Navicent allegedly violated the FCA and the Georgia False Medicaid Claims Act.

The investigation originated with a lawsuit filed by Andre Valentine, a former Navicent paramedic, under the whistleblower provisions of the False Claims Act and the Georgia False Medicaid Claims Act. These statutes allow private citizens to bring civil actions on behalf of the Government and share in any recovery obtained. Suits are filed “under seal,” or “in secret” with the state or federal court, informing authorities of the fraud, and while inspectors investigate allegations brought forward by whistleblowers.

The False Claims Act allows individuals with information about fraud on the government to bring suits on behalf of the United States to recover ill-received funds from contractors. If an individual’s suit proves successful, the “whistleblower” is generally entitled to 15-30% of recovered funds. The United States Congress adopted the law in the late 1800s to expose fraud among contractors.

The first alleged scheme resolved by the settlement concerns “non-emergency” transports between hospitals that Navicent billed at an inflated rate by claiming the ambulance trips were emergencies. The other scheme resolved by the settlement concerns the billing of non-emergency ambulance transports of patients released from the hospital to their residences, skilled nursing facilities, hospital-based diagnostic clinics, or dialysis centers that Navicent billed as emergency transports in violation of ambulance billing rules.

The complaint filed by Valentine alleged that in addition to billing many of these transports at an inflated rate, for many transports it was neither appropriate nor medically necessary for Navicent to use or bill for an ambulance at all. The U.S. Department of Health and Human Services Office of Inspector General (“OIG”) investigated Navicent’s emergency ambulance transportation services and found irregularities in billing and identified occurrences of billing for unnecessary services.

In a False Claims Act case, the government may choose to “intervene” on behalf of a whistleblower. If the government declines to intervene, a whistleblower may prosecute fraud on their own. If the government declines to intervene in a whistleblower’s case, it is not a death-blow to the suit, as billions of dollars have been recovered “privately” in “declined cases.”

As a result of Valentine’s information and the government’s investigation, on May 8, 2017, the United States and the State of Georgia chose to intervene in Mr. Valentine’s suit and litigate the case in United States District Court.

The settlement announced last week resolves the pending litigation. “Ambulance billing has long been an area of potential fraud on the Medicare and Medicaid programs and this office will continue to vigorously investigate and pursue those who attempt to take advantage of the program. We will continue to police ambulance providers throughout Middle Georgia until the message has been received,” said U.S Attorney G.F. Peterman.

Mr. Valentine will receive approximately a one-third share of the $2.5-million-dollar settlement payment pursuant to the whistleblower provisions of these statutes.

While the alleged fraud a whistleblower sees may not be as explicit as what Valentine experienced, consulting an experienced whistleblower attorney or an attorney who specializes in the False Claims Act will help evaluate and guide a potential whistleblower’s claim.

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