Boston Heart Diagnostics Corporation is still under investigation for Medicare and Medicaid fraud after the decision of a federal judge on Friday, June 9, 2017.

The whistleblower case lists the U.S. government and Tina G. as plaintiffs against the laboratory alleging they engaged in Medicare and Medicaid fraud. Tina G. is a medical doctor that works for United Healthcare. She is their National Medical Director of Women’s Health and Genetics.

United Healthcare health insurance company is an insurance clearinghouse company that offers individual and employer-based group health insurance plans, Tricare health insurance, and Medicare and Medicaid insurance coverage.

Federal False Claims Act

Tina G. originally filed her legal complaint in early February 2015. Amended complaints followed in May of 2015 and then October 2016.

Her case alleged that the Boston cardiology lab zoned in on general practitioners and other non-specialists using a variety of means to encourage them to order tests on patients that were medically unnecessary in the prediction of developing heart disease.

The sum total of these tests and billings were significant and amounted to Medicare and Medicaid fraud under the federal False Claims Act, according to Tina.

The False Claims Act essentially gives permission to people who have evidence that the U.S. government or any of its programs have been financially cheated, as in cases of Medicare and Medicaid fraud, to sue the person or entity doing so on behalf of the U.S. government.

A provision of this act known as qui tam gives the government the right to add its power behind the action or decline involvement. If government declines, the single plaintiff may still proceed to sue in court as an individual. The False Claims Act is United States Code (USC) sections 3729-3733.

What determines Medicare and Medicaid Fraud?

Medicare is a health insurance program sponsored by the federal government that assists the elderly and individuals with certain disabilities. Medicaid – also a federal program – supports the medical insurance needs of the working poor and needy with supplemental state spending. It has a more expansive coverage base that includes children, the aged, disabled, or those on Social Security-based income support.

Medicare and Medicaid fraud may be determined in part by whether or not services rendered could be justified as medically necessary for clinical and diagnostic determination of a medical condition needing treatment.

The national coverage determinations for Medicare are actually made by the Secretary of Health and Human Services. The basic standard of being “reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member,” as stated in the USC holds true, however.

In a news article by Law360, it was identified that U.S. District Court Judge Reggie B. Walton upheld certain aspects of the whistleblower case filed by plaintiff Tina G. while throwing out others.

The summary of this legal action is that Boston Heart Diagnostics Corporation will still be under investigation for allegedly fleecing the government by luring inexperienced doctors not specialized in cardiac medicine to order tests as supposedly “necessary.” These billed tests allegedly led to significant monetary payout for the Boston lab.