The United States Attorney serving the Southern District of New York has initiated a healthcare fraud lawsuit against an individual physician as well as the Metropolitan Retina Associates PC business.

This civil healthcare fraud lawsuit is brought on behalf of the U.S. government under the False Claims Act in an effort to recover damages and civil penalties associated with the defendant’s allegedly false and fraudulent claims for reimbursement under the Medicare program and the New York State Medicaid program.

According to the healthcare fraud lawsuit, between 2010 and 2017, the defendants had two distinct fraudulent schemes, each of which led to the submission of false and fraudulent reimbursement claims under Medicaid and Medicare.

Metropolitan Retina, as explained in the healthcare fraud lawsuit, is an ophthalmology practice that is owned and operated by a chief physician who is also named as a defendant in this case.

The healthcare fraud lawsuit alleges that in the first scheme for fraudulent and false healthcare claims, the defendant submitted claims for procedures that were of such poor quality that they were useless for patient care. These procedures are known as fluorescein angiography.

The procedures allegedly produced images that failed to capture the right portions of the eye so as to be readable, were out of focus and in some cases contained no fluorescein dye. In the procedures that were billed to Medicaid and Medicare, according to the healthcare fraud lawsuit, the defendants did not capture any images at all.

According to the allegations in the healthcare fraud lawsuit, the defendants engaged in a second scheme in which they were billing Medicaid and Medicare for ophthalmologic ultrasounds that were not supported by any documentation in the patients’ medical records or were not performed at all.

Healthcare Fraud Under the False Claims Act

Healthcare fraud cases involving Medicaid and Medicare involve claims for federal money, which means that the government has the opportunity to intervene in the case if the claim is brought by an individual whistleblower.

In many healthcare fraud cases, the government learns about the alleged fraud scheme because an employee or former employee who has knowledge of schemes to defraud the government reports these concerns. In doing this on good faith that fraud has occurred, the whistleblower receives protections from retaliation.

In healthcare fraud lawsuits, the U.S. government might step in after a whistleblower brings schemes associated with healthcare fraud to the government’s attention.

These whistleblowers might become aware of a fraud scheme during the usual course of doing their jobs. Some even attempt to report it to their superiors prior to taking legal action, and sometimes these claims involve false submissions to government programs involving millions of dollars.

In these kinds of False Claims Act cases involving healthcare fraud, the individual whistleblower who shares relevant evidence that is ultimately used to carry out these legal cases might be entitled to a portion of the recovery and damages retained by the U.S. government.

The Healthcare Fraud Lawsuit is Case No. 1:18-cv-09146, filed in the United States District Court, Southern District of New York.