On April 8, 2021, the U.S. Department of Justice issued a press release announcing a $22.5 million settlement with South Carolina’s largest urgent care provider – Doctors Care, P.A. (d/b/a/ “Doctors Care”) – and its management company, UCI Medical Affiliates of South Carolina, Inc. (“UCI”).  The settlement resolves alleged False Claims Act violations (“FCA”). 

The federal FCA imposes liability on “any person who [among other things] … knowingly presents, or causes to be presented, a false or fraudulent claim for payment” to the federal government or who “knowingly makes, uses, or causes to be made or used, a false record or statement material to a false or fraudulent claim.”  31 U.S.C. § 3729(a).  Those who violate the FCA are liable for civil penalties of over $23,000 per claim, plus treble damages.  Id. at §3729(a)(1)(G).  The case against Doctors Care was brought under the qui tam provisions of the FCA, which allow a whistleblower (known as a “relator”) to initiate an FCA action on behalf of the government and to receive a portion of the recovery.  

According to the press release, Doctors Care allegedly committed an unfortunately all-too-common violation – submitting claims under the billing credentials of a provider that did not provide services to the patient or did not provide services as detailed in the submitted claim.  Such submissions may violate the FCA.  CG attorneys discussed a federal case with similar facts that resulted in over $1.1 million in damages and penalties. 

For a period of over five years (as early as 2013 and continuing to 2018), UCI allegedly could not secure and maintain necessary billing credentials for most of Doctors Care’s providers.  The press release notes that UCI knew that federal insurance programs would not pay claims submitted with the billing number of an uncredentialed provider and developed a scheme to link uncredentialed providers with credentialed providers.  Claims of uncredentialed providers were allegedly submitted using the billing number of the linked credentialed provider, who did not render the care described in the submitted claim.  The government alleges the existence of email evidence memorializing the linking scheme and cheat sheets used to track properly credentialed providers.  

In addition to the $22.5 million settlement, Doctors Care and UCI entered into a Corporate Integrity Agreement, which includes claim reviews for five years by an Independent Review Organization and monitoring.  While the press release did not provide the whistleblower’s share of the qui tam action, the potential recovery for whistleblowers presents a lucrative opportunity.  Whistleblowers of a successful case are entitled to 15% to 30% of the money the government recovers, depending on whether the government intervened. 

The press release also provides two important notes about the investigation.  First, the settlement occurred after a three-year investigation, which is consistent with FCA cases and investigations that are notorious for lasting many years.  Second, the investigation was a cross-agency coordinated effort that included the U.S. Department of Health and Human Services Office of Inspector General (“HHS-OIG”) and the United States Department of Defense Criminal Investigative Service (“DCIS”) and its law enforcement partners.

The attorneys at Chilivis Grubman represent clients of all types and sizes in connection with False Claims Act investigations and related litigation.  If you need assistance with such a matter, please contact us today.