United States Settles Medicare Billing Fraud Lawsuit With Multi-Specialty Health Care Provider For $1 Million

Preet Bharara, the United States Attorney for the Southern District of New York, and Thomas O’Donnell, Special Agent-in-Charge of the Department of Health and Human Services, Office of Inspector General (HHS-OIG), New York region, announced today that the United States has settled for $1 million a civil health care False Claims Act lawsuit it filed on March 5, 2013 in Manhattan federal court against PARK AVENUE MEDICAL ASSOCIATES, P.C., PARK AVENUE HEALTH CARE MANAGEMENT, LLC, and PARK AVENUE HEALTH CARE MANAGEMENT, INC. (collectively “PAMA”), affiliated companies in the business of providing multi-specialty medical services in New York. This settlement resolves a lawsuit alleging that PAMA billed Medicare for services purportedly provided to elderly, mentally ill patients that were not medically necessary, were not documented in the medical record, or failed otherwise to comply with Medicare rules and regulations. The settlement was approved today by U.S. District Court Judge Colleen McMahon.

Manhattan U.S. Attorney Preet Bharara said: “In these lean budget times, it’s especially important that federal dollars be reserved for Medicare’s prescribed purposes, and not lost to fraud or abuse by companies like Park Avenue Medical Associates. This Office will continue to work hard to protect the Medicare program and prevent taxpayers from paying for unnecessary services.”

HHS-OIG Special Agent-in-Charge Thomas O’Donnell said: “For over a dozen years, Park Avenue Medical Associates submitted fraudulent claims to pad their pockets at Medicare’s expense, a practice that will simply not be tolerated. Through this settlement, PAMA is owning up and paying the price for their misconduct.”

According to the allegations contained in the Complaint filed in March 2013 in Manhattan federal court:

PAMA directly employs physicians, nurses and other medical professionals who provide services to elderly patients at hospitals, including inpatient psychiatric facilities, nursing homes, and assisted living facilities, among other types of long-term care facilities. The patients and residents at these facilities suffer from various chronic health conditions, including Alzheimer’s disease, dementia, schizophrenia, psychosis, depression and anxiety. The doctors and nurses employed by PAMA receive a salary from PAMA, which contracts with the facilities. In addition to their regular salaries, psychiatrists and psychologists employed by PAMA receive bonuses based on how many services they provide and the level of reimbursement they generate for PAMA from government and other insurance providers, including Medicare.

Medicare prohibits payment for services that are not “reasonable and necessary” for the diagnosis or treatment of an illness or injury. Medicare also prohibits payment for any claim without adequate documentation substantiating the reasonableness and necessity of the services provided. In particular, Medicare does not cover psychotherapy services rendered to patients with Alzheimer’s disease or dementia unless the patient’s dementia is mild, the patient has the capacity to recall what occurred at the therapy from one session to the next, and that capacity is documented in the patient’s record. Psychotherapy services are not covered when dementia has produced a severe enough cognitive defect to prevent psychotherapy from being effective. In addition, Medicare provides that psychiatric diagnostic examinations are covered only once for each episode of illness or suspected illness in a patient.

In violation of Medicare policies, as well as its own policies, PAMA provided psychotherapy to patients who lacked the capacity to benefit from it due to severe dementia. In addition, PAMA billed for psychiatric evaluations that were duplicative, failed to comply with Medicare rules, and reflected a lack of coordination of care both among PAMA’s own psychiatrists, psychologists and nurses, and between PAMA’s employees and staff at the facilities at which PAMA performed services. In fact, PAMA billed Medicare for a far larger number of all of these services per psychiatrist and psychologist during the period 2001 through 2012 than any other provider with a similar patient population in the New York area.

In the settlement, PAMA admitted the following:

• In many instances, PAMA billed Medicare for psychiatric diagnostic examinations without demonstrating that they had adequately documented the patient’s medical and/or psychiatric history and/or mental status;
• In many instances, PAMA billed Medicare for multiple psychiatric diagnostic examinations after receiving multiple orders for such, but without demonstrating that the examinations complied with certain applicable Medicare rules, including those that allow for multiple examinations only when there is a demonstrated hiatus in the condition of the patient or the beginning of a new spell of illness; and
• In many instances, PAMA billed Medicare for psychotherapy services to patients who suffered from dementia or other cognitive disorders without demonstrating that the patients had the capacity to benefit from the psychotherapy.

As part of the settlement, PAMA also entered into a Corporate Integrity Agreement with the U.S. Department of Health and Human Services Office of Inspector General.

Mr. Bharara thanked the Department of Health and Human Services, Office of the Inspector General, for its assistance in this case.

This case is being handled by the Office’s Civil Frauds Unit. Assistant U.S. Attorneys Heidi A. Wendel and Mara E. Trager are in charge of the case.

U.S. v. Park Ave Medical Associates, et al. Stipulation and Settlement
U.S. v. Park Ave Medical Associates, et al. Complaint