The settlement resolves allegations that, from Jan. 1, 2020, to Oct. 31, 2020, Gamma and the Murphys submitted or caused to be submitted claims to Medicare for medically unnecessary polymerase chain reaction (PCR) urinalysis laboratory tests that were not ordered by treating physicians. When a physician ordered a urinalysis (UA) with culture and sensitivity (C&S) or just a C&S, Gamma automatically performed, and submitted claims for payment to Medicare for, a urinary tract infection (UTI) panel of tests by PCR (the UTI PCR Tests).
Medicare reimbursements for the UTI PCR Tests were significantly higher than reimbursements for a UA with C&S — on average, Medicare paid approximately $11 for a UA with C&S but paid an additional $573 for a panel of UTI PCR Tests. Gamma’s requisition forms were structured in a way that did not allow physicians to opt out of the UTI PCR Tests. Physicians expressed concerns to Gamma about the UTI PCR Tests as early as March 2020, including concerns that they did not order the tests, that the tests were expensive and that they were not medically necessary.
The civil settlement includes the resolution of claims brought under the qui tam or whistleblower provisions of the False Claims Act by Bradley Bibb M.D., a physician who owns a number of health care clinics and provided services to patients for whom Gamma performed laboratory tests. Under those provisions, a private party can file an action on behalf of the United States and receive a portion of any recovery. The qui tam case is captioned United States ex rel. Bibb v. Gamma Healthcare Inc. et al., No. 1:20-cv-00250-SNLJ (E.D. Mo). Bibb will receive $2,315,342.23 of the proceeds from the settlement.
The resolution obtained in this matter was the result of a coordinated effort between the Justice Department’s Civil Division, Commercial Litigation Branch, Fraud Section and the U.S. Attorney’s Office for the Eastern District of Missouri, with substantial assistance from HHS-OIG and FBI. Trial Attorney Elizabeth J. Kappakas of the Civil Division’s Fraud Section and Assistant U.S. Attorney Suzanne Moore for the Eastern District of Missouri handled the matter, with the assistance of Financial Analyst Sheryl Paynter of the Civil Division.
The investigation and resolution of this matter illustrates the government’s emphasis on combating health care fraud. One of the most powerful tools in this effort is the False Claims Act.
The claims resolved by the settlement are allegations only and there has been no determination of liability.