Data Analytics Firm Files Qui Tam Based on Billing Outliers

Earlier this month, a federal court unsealed a declined qui tam complaint filed by a data analytics firm based on identification of Medicare billing outliers.  See United States ex rel. Lincoln Analytics, Inc. v. Global Integrated Medical Group, Inc., No. 2:22-cv-06501 (C.D. Cal.).  Despite asserting a claim as an original source, the relator, Lincoln Analytics, Inc., appears to have assembled its allegations through its own analysis of Medicare data and a single interview.  DOJ has increasingly been deploying data analytics to develop FCA cases (as discussed here and here) and this unsealed complaint demonstrates that relators are also beginning to use data analytics in a similar manner.

The relator alleged that the defendants (a home health agency, its chief executive officer, and its chief financial officer) billed Medicare for excessive care plan oversight (“CPO”) services.  Medicare’s Claims Processing Manual requires physicians to spend at least 30 minutes supervising a patient in order to bill for CPO services.  The relator’s analysis revealed that the two highest-billing physicians across the entire Medicare program for CPO services in 2019 and 2020 both work for the defendants.  The relator explained that one physician’s 2019 CPO billings, “if true, would indicate that he worked the equivalent of approximately 419.5 24-hour days in 2019 solely on care plan oversight, which is physically impossible.”  To further underscore the extent to which these physicians were outliers, the relator noted that the “mean provider in 2018, 2019, and 2020 received approximately $22,503.97 for care plan oversight services, and 99 percent of providers received $237,410.26 or less over those three years”—less than one-tenth of the amount billed by the top outlier.  The relator alleged, merely “on information and belief,” that the defendant home health agency “billed Medicare for care plan oversight services in [the outlier physician’s] name based on automatic systems . . . regardless of whether the patients or care met Medicare’s requirements for CPO services.”

Despite the relator’s use of data analytics, DOJ declined to intervene in this case, and made that decision only ten months after the relator filed its complaint.  A copy of the qui tam complaint can be found here.

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