The United States Attorney’s Office for the Eastern District of Oklahoma announced that DR. DANIEL CASTRO, an Otolaryngologist who practiced, from 2005 to 2010, at the Medical Center of Southeastern Oklahoma (MCSO), located in Durant, Oklahoma, has agreed to pay $275,000 to the United States and the State of Oklahoma to resolve allegations that he billed SoonerCare, the Oklahoma Medicaid Program, for surgical procedures that he performed and related office services, that were not performed as claimed and/or were not medically necessary. During the time in question, MCSO was owned by Healthcare Management Associates (HMA). In January of 2014, HMA was acquired by Community Health Systems, a nationwide acute care hospital chain.
United States Attorney Mark Green stated; “It is one of our office’s highest priorities to protect the citizens of our district against unscrupulous health care providers who don’t play by the rules. Performing unnecessary surgery not only harms patients but also wastes taxpayer dollars. The False Claims Act is a valuable weapon in the government’s arsenal to combat these types of abuses.”
The settlement announced today resolves allegations that Dr. Castro submitted claims to SoonerCare for surgical procedures known as functional endoscopic sinus surgeries (FESS) which require no incisions on the face but instead involve the insertion of a nasal endoscope, a very thin fiber optic tube, into the nose for a direct visual examination and clearing of the openings into the sinuses. The related office services that were not performed as claimed are known as endoscopic debridements, procedures performed by an otolaryngologist following a FESS in which an endoscope, or fiber optic tube, is inserted into the nose for a thorough inspection and removal of dried blood and crusting.
In a related settlement, HMA paid the United States and the State of Oklahoma $1.5 million dollars to resolve allegations that MCSO billed SoonerCare, the Oklahoma Medicaid Program, for surgical procedures performed by Dr. Daniel Castro and related hospital services that were not medically necessary.
The allegations that the government has settled with Dr. Castro and HMA were raised in a lawsuit filed under the qui tam, or whistleblower, provisions of the False Claims Act. The Act allows private citizens with knowledge of fraud to bring civil actions on behalf of the government and to share in any recovery. The whistleblower, Sandra Simmons, will receive a share of today’s settlement. The Act also permits the government to intervene in the whistleblower’s suit, as the government did here.
This civil settlement and the government’s intervention illustrate the government’s emphasis on combating health care fraud and mark another achievement for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced in May 2009 by then Attorney General Eric Holder and Health and Human Services Secretary Kathleen Sibelius. The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation. One of the most powerful tools in this effort is the False Claims Act. Since January 2009, the Justice Department has recovered a total of more than $26.7 billion through False Claims Act cases, with more than $16.8 billion of that amount recovered in cases involving fraud against federal health care programs.