Physician Partners of America LLC (PPOA), along with its founder Rodolfo Gari, and former chief medical officer Dr. Abraham Rivera, have agreed to a significant settlement of $24.5 million. This resolution addresses allegations of violating the False Claims Act by improperly billing federal healthcare programs. The accusations include billing for medically unnecessary tests and services, providing unlawful kickbacks to physician employees, and making false statements related to a loan obtained through the Paycheck Protection Program (PPP). Several PPOA affiliates, including Florida Pain Relief Group and Texas Pain Relief Group, are jointly liable for this settlement.
The core of the allegations against Physician Partners of America and its pain relief group centers on the practice of submitting claims for urine drug testing (UDT) that were not medically necessary. The government contended that PPOA mandated its physician employees to order multiple UDTs concurrently, without properly assessing the necessity of each test. Furthermore, it was alleged that PPOA did not consistently review initial test results (presumptive UDT) to determine if further, more detailed testing (definitive UDT) was actually required. Despite this, PPOA’s affiliated toxicology lab reportedly billed federal healthcare programs for the most expensive level of UDT.
Adding to these concerns, the government further alleged that Physician Partners of America incentivized its physicians to order presumptive UDTs by offering them 40% of the profits generated from these tests. This practice is a potential violation of the Stark Law, which is designed to prevent physicians from referring patients for “designated health services” payable by Medicare or Medicaid to entities with whom they have a financial relationship, unless a specific exception applies. This financial incentive structure allegedly influenced medical decisions within Physician Partners of America and its pain relief group practices.
Beyond urine drug testing, the allegations also extended to genetic and psychological testing. The United States claimed that Physician Partners of America required patients to undergo both genetic and psychological evaluations before they were even examined by a physician. This protocol was allegedly implemented without any prior determination of whether these tests were medically appropriate or necessary for the individual patient. Subsequently, federal healthcare programs were billed for these tests, raising further questions about billing practices at Physician Partners of America and its affiliated pain relief group.
The government’s case also highlighted actions taken by Physician Partners of America during the COVID-19 pandemic. When Florida suspended non-emergency medical procedures in March 2020, Physician Partners of America reportedly sought to offset lost revenue through questionable billing practices. It is alleged that they directed their physician employees to schedule patient evaluation and management (E/M) appointments every 14 days, a significant increase from their previous practice of monthly appointments. Moreover, PPOA allegedly instructed physicians to bill these more frequent E/M visits using inappropriately high-level procedure codes, maximizing reimbursement.
Compounding these issues, the United States government further alleged that while engaging in this potentially unlawful overbilling, Physician Partners of America applied for and received a $5.9 million loan through the SBA’s Paycheck Protection Program. In their loan application, PPOA allegedly falsely certified that they were not engaged in any unlawful activities. The settlement announced today covers liabilities under both the False Claims Act and the Financial Institutions Reform, Recovery and Enforcement Act (FIRREA), stemming from the alleged false claims submitted to federal healthcare programs for the E/M visits and the false statement made in connection with the PPP loan.
Principal Deputy Assistant Attorney General Brian M. Boynton, head of the Justice Department’s Civil Division, emphasized the importance of these actions, stating, “Billing federal healthcare programs for services that providers know are unnecessary or unreasonable undermines the quality of care that patients receive and increases the costs of these taxpayer-funded programs.” He affirmed the department’s commitment to ensuring that healthcare providers prioritize patient needs over financial gain in their treatment decisions.
U.S. Attorney Roger B. Handberg for the Middle District of Florida echoed this sentiment, stating, “Holding healthcare providers accountable for inflated claims and false statements helps ensure the integrity of the healthcare system as a whole.” He emphasized that settlements like this one are crucial for maintaining a fair and ethical healthcare environment.
General Counsel Peggy Delinois Hamilton of the SBA highlighted the agency’s focus on integrity in pandemic relief distribution. “The SBA takes fraud seriously and will continue to make it our priority to work alongside the Office of the Inspector General to identify and address any potential fraud to ensure sound administration of relief programs,” she stated.
In conjunction with the financial settlement, Physician Partners of America also entered into a five-year Corporate Integrity Agreement (CIA) with the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG). This CIA mandates significant compliance measures for PPOA, including establishing a compliance department, appointing a medical director and oversight board, retaining a compliance expert, providing management certifications, developing written standards, training and education programs, undergoing annual claims reviews by an Independent Review Organization, implementing risk assessment and internal review processes, and monitoring testing referrals.
Special Agent in Charge Omar Pérez Aybar of HHS-OIG underscored the impact of healthcare fraud, noting, “When health care providers bill taxpayer-funded health care programs for medically unnecessary services, they divert government funds designed to assist business owners during this pandemic.” He affirmed the agency’s dedication to investigating healthcare fraud schemes in partnership with law enforcement.
Director Christopher Godfrey of the Department of Labor (DOL) Office of Workers’ Compensation Programs (OWCP) explained the financial recovery aspect, stating, “This settlement allows OWCP to recover medical bill payments under the Federal Employees’ Compensation Act and return those funds to the Employees’ Compensation Fund.” He emphasized the DOL’s commitment, alongside its OIG and other agencies’ OIGs, to detecting abuse within the FECA program and ensuring appropriate use of program funds.
Special Agent in Charge Cynthia A. Bruce of the Department of Defense Office of Inspector General, Defense Criminal Investigative Service (DCIS), Southeast Field Office, highlighted the erosion of trust caused by profit-driven healthcare practices. “When actors within our health care system are focused on profit rather than patient care, it undermines the integrity of the medical decision-making process,” she said, reaffirming DCIS’s commitment to protecting Defense Health Agency funding.
Special Agent in Charge David Spilker of the Department of Veterans Affairs Office of Inspector General’s (VA OIG) Southeast Field Office, emphasized the importance of safeguarding veteran healthcare programs. “This civil settlement reinforces the VA OIG’s commitment to safeguarding the integrity of VA’s healthcare programs and operations and preserving taxpayer funds,” he stated, referencing the VA’s Community Care programs.
Special Agent in Charge Amy K. Parker of the U.S. Office of Personnel Management, Office of the Inspector General (OPM OIG), addressed the impact on federal employees’ health benefits. “When providers submit false claims for medically unnecessary tests, they are not only violating their patients’ trust but also compromising the integrity of the Federal Employees Health Benefits Program (FEHBP),” she stated, highlighting OPM OIG’s dedication to protecting patients and the FEHBP from fraudulent claims.
The settlement also involved the resolution of claims brought under the qui tam or whistleblower provisions of the False Claims Act by several current or former employees of PPOA and its affiliates, including Donald Haight, Dawn Baker, Dr. Harold Cho, Dr. Venus Dookwah-Roberts, and Dr. Michael Lupi. These whistleblowers, who initiated the legal action, will receive a portion of the recovered funds as предусмотрено under the False Claims Act. The qui tam cases are listed as United States ex rel. Haight v. Physician Partners of Am.; United States ex rel. Baker v. Physician Partners of Am LLC; United States ex rel. Lupi v. Physician Partners of Am. LLC; and United States ex rel. Dookwah-Roberts v. Physician Partners of Am. LLC.
This resolution was a collaborative effort between various government agencies, including the Justice Department’s Civil Division, Commercial Litigation Branch, Fraud Section; the U.S. Attorney’s Office for the Middle District of Florida; HHS-OIG; VA OIG; DCIS; DOL OIG; and OPM OIG. This interagency cooperation underscores the government’s commitment to combating healthcare fraud.
The Department of Justice emphasizes the importance of the False Claims Act as a powerful tool in combating healthcare fraud and encourages reporting of potential fraud, waste, abuse, and mismanagement through the HHS hotline (800-HHS-TIPS). The establishment of the COVID-19 Fraud Enforcement Task Force in May 2021 further demonstrates the government’s proactive approach to preventing and combating pandemic-related fraud, including fraud affecting COVID-19 government relief programs like the PPP. Individuals with information about COVID-19 fraud can report it through the Civil Division’s Fraud Section webpage or the Department of Justice’s National Center for Disaster Fraud (NCDF) Hotline at 866-720-5721.
The case was handled by Senior Trial Counsel David W. Tyler of the Civil Division and Assistant U.S. Attorney Lindsay Saxe Griffin for the Middle District of Florida.
It is important to note that the claims resolved by this settlement are allegations, and there has been no formal determination of liability.
