A Southern California-based ophthalmology group, its former CEO and several of its physicians have paid the United States and California $6.65 million to settle False Claims Act allegations that they defrauded public health care programs by billing for unnecessary eye exams, improperly waiving Medicare co-payments, and violating other regulations, the Justice Department announced Friday.
Retina Institute of California Medical Group (RIC), is a medical partnership of ophthalmologists who specialize in the treatment of retinal diseases. RIC operates in multiple locations in Los Angeles, Orange and Riverside counties. On Oct. 2, the RIC and several other defendants paid the United States $6,353,410 and paid California $296,590 pursuant to a settlement agreement.
The other defendants who participated in the settlement are:
- Tom S. Chang of Pasadena.
- Tom S. Chang, M.D., Inc., a Pasadena-based company.
- Michael A. Samuel of Arcadia.
- Michael J. Davis also of Arcadia.
- Brett Braun, former CEO of Retina Institute of California Medical Group.
- California Eye and Ear Specialists, a Pasadena-based subsidiary of Trilogy Eye Medical Group Inc., a company for whom Chang and Samuel serve as senior executives.
- San Gabriel Ambulatory Surgery Center LP, a San Gabriel-based company.
Between January 2006 and August 2017, the defendants allegedly violated the False Claims Act by submitting bogus claims to Medicare and Medicaid/Medi-Cal, according to a settlement agreement signed in this case. Medicare reimburses physicians for examining patients, paying more money as the medical exams performed increase in complexity. RIC personnel allegedly improperly billed public health programs by misclassifying simpler exams as being more complex, using billing codes normally used for patients with severe or emergency conditions.
RIC and the other defendants also allegedly waived Medicare co-payments and deductibles without proper documentation of patients’ financial hardship, which was intended to induce referrals. The defendants allegedly also billed Medicare and Medicaid for medical services that weren’t performed, were unnecessary, not documented in the medical record or were not in compliance with applicable rules and regulations.
The allegations were made in a whistleblower lawsuit filed in United States District Court by Bobbette A. Smith and Susan C. Rogers, who formerly worked for RIC as administrators, under the qui tam – or whistleblower – provisions of the False Claims Act. These provisions permit private individuals to sue on behalf of the government for false claims and to share in any recovery. The United States may intervene in the lawsuit, or, as in this case, the whistleblower may pursue the action. Smith and Rogers will receive a share of the settlement, but that amount has not yet been determined.
The case, which was filed in May 2013 and unsealed in July 2016, was monitored by the United States Attorney’s Office, as well as the U.S. Department of Health and Human Services – Office of Inspector General.
The claims settled are allegations only and the defendants did not admit liability.
The lawsuit is captioned United States, et al., ex rel. Smith and Rogers v. Tom S. Chang, M.D., et al., No. 13-CV-3772-DMG (C.D.Cal.).