Full title: UNITED STATES OF AMERICA, ex. rel., SANTHOSH REDDY DEVARAPALLY, M.D.…
Court: United States District Court, E.D. North Carolina, Western Division
Date published: Mar 2, 2023
Facts
The relevant facts alleged in the complaint may be summarized as follows. Defendant Ferncreek is a Professional Association in North Carolina that provides a full range of cardiology services. (Compl. ¶¶ 18, 20). Defendants Matthew A. Daka, M.D. (“Daka”); Selvaratnam Sinna, M.D. (“Sinna”); and Manesh Thomas, M.D., (“Thomas”), have been partners in the practice since at least 2014, and Defendant Suriya Bandara Jayawardena, M.D., (“Jayawardena”), is a former partner on whose behalf Ferncreek billed claims at from at least 2014 to 2019. Relator worked for Ferncreek as a cardiologist during 2014 and 2015.
Medicare, Medicaid, and TRICARE (“the federal programs”) are federally funded health care programs (Compl. ¶¶ 25, 69, 86). Medicare makes payments directly to providers (compl. ¶ 31), who must comply with the requirements of the program in order to be reimbursed for services. (Id. ¶¶ 34-39). As relevant here, Medicare requires doctors to certify that they have abided or will abide by program policies, (id. ¶¶ 35-41), provide services only when they are medically necessary, (id. ¶¶ 65-66), and keep accurate records. (Id. ¶ 67). Medicaid and TRICARE have similar requirements. (Id. ¶¶ 72-73, 76-78, 80-81, 89-92, 94-95). The programs receive millions of claims per year, and it is not feasible to audit each claim. (Id. 54, 85). The North Carolina Department of Health and Human Services, Division of Health Benefits (NCDHB) administers the Medicaid program in the state of North Carolina. (Id. ¶ 70).
When testing for the diseases at issue in this case, peripheral arterial disease (“PAD”) and coronary artery disease (“CAD”), physicians often order non-invasive tests before or as an alternative to invasive procedures. (Id. at ¶¶ 102-04, 115-23, 125-126). The complaint alleges that individual defendants intentionally falsified the results of non-invasive tests, ordered invasive tests even after non-invasive tests returned normal results, or failed to conduct non-invasive tests at all as part of a scheme to bill the federal programs for more lucrative, invasive tests. (E.g., id. ¶¶ 165167). Individual defendants allegedly each performed and billed the federal programs for all the following invasive diagnostic procedures: leg catheterizations to test for PAD, coronary catheterization imaging to test for CAD, and cardiac stent placement, also to diagnose CAD. (Id. ¶ 3).
As part of the alleged scheme, individual defendants held a meeting with Relator in 2014. (Id. ¶ 170). In that meeting, defendant Sinna “instructed [relator] to find symptoms to justify procedures, and . . . explained that referring patients for leg and carotid imaging procedures would generate revenue for [r]elator’s bonuses (including during stent follow-up visits).” Id. Defendants Daka and Sinna held an additional meeting with the relator in 2015, in which they pushed [relator] to increase his referrals for leg catheterizations and cardiac stents, instructed him to increase leg catheterizations (that were performed in the office), and documented that patients had pain in their leg when walking as a reason for PAD procedures even if false, and further instructed him to refer all patients for cardiac catheter angiograms and stents if their Troponin blood test were 0.5 or greater, regardless of whether the Triponin level could be explained by other indicated medical conditions.
Issue
Decision
Based on the foregoing, defendants’ motion to dismiss (DE 52) is DENIED. Where the court stayed previously case scheduling conference activities pending decision on the instant motion, the court now LIFTS such stay. Where the parties superseded their first set of consent motions for protective orders by subsequent motions, the consent motions filed January 10, 2023 (DE 66-67) are TERMINATED AS MOOT. The second set of motions for protective orders (DE 68-69) will be addressed by separate order. An initial order regarding planning and scheduling will follow so that the parties can submit a new Rule 26(f) report for entry of a case management order.
SO ORDERED,