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Sidley False Claims Act Blog DOJ settles FCA case alleging medically unnecessary telehealth visits, recovers PPP money

This Week DOJ announcement one of the first civil settlements under the FCA involving the abuse of pandemic flexibilities that the Department of Health and Human Services used to allow wider use of telehealth during the COVID public health emergency. Physician Partners of America (“PPOA”) has agreed to pay $24.5 million to resolve allegations that it violated the FCA by charging for medically unnecessary telehealth visits and submitting claims for genetic, psychological and medically unnecessary urine and claims tainted with Stark law violations. Although the DOJ has already initiated criminal actions related to the abuse of telehealth waiver flexibilities, as discussed below herethis case represents an extension of the examination of the application of telehealth to the civilian side.

According to the DOJ, after the suspension of non-emergency medical procedures in early 2020 due to the pandemic and falling revenues, the PPOA ordered its doctors to see patients via telemedicine twice a month, regardless of the need. , and to bill these assessment and management visits with inappropriate visits. high-level procedural codes. The DOJ further alleged that, in connection with obtaining a $5.9 million loan through the Paycheck Protection Program (“PPP”), PPOA falsely stated that it was not engaged in illegal conduct. In the past, the DOJ’s Civil Division has typically prosecuted PPP loan fraud related to the misuse of PPP funds or the fraudulent receipt of duplicate loans; The DOJ’s decision to leverage alleged health care billing irregularities that are completely separate from PPP eligibility requirements as a means of recovering PPP funds may represent a new trend in enforcement.

This regulation reinforces the fact that the abuse of regulatory flexibilities in telehealth remains an enforcement priority for the federal government.