ATLANTA (November 23, 2021)—PruittHealth, Inc. and affiliated entities have agreed to pay $4.2 million to resolve allegations that they submitted claims for home health services that were not covered by the Medicare and Medicaid programs, and that they failed to refund overpayments that they had received from Medicare and Medicaid in a timely manner.
“The Medicare and Medicaid programs depend on providers to submit only those claims that are eligible for reimbursement and to promptly notify the programs if they receive payments to which they are not entitled,” said U.S. Attorney Kurt R. Erskine. “Health care providers must not place their own financial well-being ahead of their duties under the Medicare and Medicaid programs.”
“When health care entities seek to boost their profits through improper billing, they undermine the trust taxpayers extend to the health care industry,” said Special Agent in Charge Derrick L. Jackson. “This settlement demonstrates the commitment that our agency and its law enforcement partners have to pursuing those who seek to improperly enrich themselves at the expense of federal health care programs.”
“When funds from programs like Medicare and Medicaid are not used as intended, taxpayers and people who are entitled to those funds suffer,” said Chris Hacker, Special Agent in Charge of FBI Atlanta. “This settlement is the result of the FBI’s commitment to work with our federal and state partners to ensure that federally funded healthcare programs are not abused by providers.”
Home health services consist of skilled care provided to homebound beneficiaries for the treatment of acute illnesses and injuries. As a result of widespread fraud in the submission of home health claims, Medicare and Medicaid began requiring referring physicians to certify in writing, after a face-to-face visit with the beneficiary, that the beneficiary was homebound and needed the skilled care. Medicare and Medicaid also require the physician to devise and sign a plan of care for the beneficiary.
The government alleges that from Jan. 1, 2011 through June 30, 2012, Pruitt knowingly submitted claims to Medicare and Medicaid for home health services that were not eligible for reimbursement because, among other things, they did not have the required face-to-face certifications or plans of care, and they did not document the beneficiary’s homebound status or need for the home health services. The government further alleges that Pruitt learned that it had received payments for home health services to which it was not entitled, but failed to disclose its receipt of the overpayments, or refund the overpayments to Medicare and Medicaid in a timely manner.
In reaching its settlement with Pruitt, the government took into account documents produced by Pruitt indicating that Pruitt subsequently took steps to improve its compliance with the home health requirements of the Medicare and Medicaid programs, including the retention of an outside consultant in January 2013 to conduct an audit of its home health claims, the implementation of a pre-bill review of home health claims between February 2013 and August 2013, and the implementation of quarterly audits of its home health claims (with more frequent audits as needed) beginning in September 2013 through the present. Pruitt voluntarily produced the results of its 2013 audit to the government during the investigation. Although the government has taken these steps into consideration, this is not an indication or concession as to the sufficiency of these compliance measures.
This settlement resolves a lawsuit originally filed in the U.S. District Court for the Northern District of Georgia by Tina Peery (the Relator) under the qui tam or whistleblower provisions of the False Claims Act: United States ex rel. Tina Peery v. UHS-Pruitt Holdings, Inc., et al., No. 1:14-cv-01016-AT. Under the False Claims Act, private citizens may bring suit for false claims on behalf of the United States and share in any recovery obtained by the government. The Relator will receive over $700,000.00 from the settlement.
The claims resolved by the settlement are allegations only, and there has been no determination of liability.
This case was investigated by the U.S. Attorney’s Office for the Northern District of Georgia, the U.S. Department of Health and Human Services Office of Inspector General, The Federal Bureau of Investigation, and the Georgia Medicaid Fraud Control Unit.
The civil settlement was reached by Assistant U.S. Attorneys Neeli Ben-David and Anthony DeCinque, as well as Georgia Assistant Attorney General Sara Vann.