GREENSBORO, N.C (STL.News) Preferred Pain Management & Spine Care, P.A. (PPM) and its owner, Dr. David Spivey, have agreed to pay $789,292.95 to resolve civil allegations that PPM violated the False Claims Act by billing Medicare, Medicaid, and other federal health care programs for medically unnecessary urine drug testing (UDT) between June 1, 2014 and May 24, 2017, announced Acting U.S. Attorney Sandra J. Hairston.
The United States alleged that PPM knowingly submitted or caused the submission of false claims to federal health care programs for presumptive and definitive UDT, in circumstances where such testing was not medically reasonable or necessary. Presumptive UDT are tests that screen for the presence of drugs, and definitive UDT are tests that identify the concentration of those drugs in a patient’s system. The government alleged that PPM and Spivey automatically ordered both presumptive and definitive UDT for all patients at their monthly visits, without conducting individualized determinations of need or risk profile.
The United States further contended that PPM billed Medicare for specimen validity testing, a quality control process used to analyze a urine specimen to ensure that it has not been diluted or adulterated. Since January 2014, Medicare’s guidance has been explicit that specimen validity testing should not be separately billed to Medicare. The United States asserted that PPM nonetheless submitted claims to Medicare for specimen validity testing throughout 2014 and 2015.
This settlement resolves allegations originally brought in a lawsuit filed by a whistleblower under the qui tam provisions of the False Claims Act, which allow private parties to bring suit on behalf of the government and to share in any recovery. The whistleblower will receive $118,911.12 as her share of the federal recovery in this case, excluding recovery for allegedly improper specimen validity testing separately identified by the United States. Tips and complaints from all sources about potential fraud, waste, abuse, and mismanagement can also be reported to the Department of Health and Human Services at 800-HHS-TIPS (800-447-8477).
“Our District is committed to ensuring that federally-funded medical procedures are ordered based on each patient’s medical needs and not for the purpose of increasing a provider’s profits,” said Acting United States Attorney Sandra Hairston. “We will continue to identify and pursue providers who submit false claims that lead to unnecessary costs for taxpayer-funded health care programs.”
“It is vital that agencies work together to hold health care providers accountable for the misuse of taxpayer funds,” said Lori A. Ahlstrand, Regional Inspector General for Audit Services at the U.S. Department of Health and Human Services. “With the use of forensic tools, our auditors identified suspicious billing and partnered closely with our Office of Counsel and the United States Attorney’s Office.”
This case was handled by the U.S. Attorney’s Office for the Middle District of North Carolina with assistance from the U.S. Department of Health and Human Services, Office of Counsel to the Inspector General, as well as the North Carolina Attorney General’s Medicaid Investigations Unit, the Office of Personnel Management, Office of Inspector General, and the Department of Veterans Affairs, Office of Inspector General. The United States was represented by Assistant United States Attorney Cassie Crawford.
The lawsuit is captioned United States ex rel. Kovalich v. Preferred Pain Management & Spine Care, P.A. et al., No. 18-CV-44 (M.D.N.C.). The claims settled by this agreement are allegations only, and there has been no determination of liability. The Settlement Agreement is not an admission of liability or wrongdoing by PPM.