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A Medicare Fraud Case, and a Battle of the Experts

United States ex rel. Montcrieff v. Peripheral Vascular Associates – Part I

United States ex rel. Montcrieff v. Peripheral Vascular Associates was decided in December 2020 before the U.S. District Court in the Western District of Texas.  The case involved a group of Relators who witnessed alleged Medicare Fraud committed by the healthcare provider Peripheral Vascular Associates (“PVA”).  PVA allegedly submitted false claims to the Medicare program by billing for services before they were complete, and for billing for services that were never ordered by a doctor. 

The Parties

The plaintiffs in the case are known as “Relators.”  Under the False Claims Act, an individual Relator who comes forward with allegations of fraud in the Medicare system can bring a legal action against the alleged provider on behalf of the United States Government, which is an awesome power indeed!

On the other side of the ledger is the defendant, a healthcare provider called Peripheral Vascular Associates (“PVA”).  PVA is a full-service vascular surgery practice with multiple locations throughout San Antonio, Texas.  Among PVA’s many services, PVA performs vascular ultrasounds, which can be ordered either by a PVA doctor, or by an outside referring doctor. 

PVA’s Processes on Vascular Ultrasounds

PVA’s provision of vascular ultrasounds is of particular importance in the Montcrieff case.  Vascular ultrasounds have two components that are relevant in this case:

  1. Technical component: This component is the actual performing of the ultrasound on a patient.
  2. Professional component: This component is when a physician analyzes the results of the ultrasound.

When PVA performed one or both of those components, it submitted a bill for reimbursement of the procedure’s cost to Medicare, an insurance company, or an uninsured patient, whomever the appropriate payor is. 

The technical and professional components of a vascular ultrasound can be either billed separately or jointly, it all depends on who performs the study.  For example, if a hospital performs the ultrasound, but a PVA physician reads and interprets the results, then the hospital would bill for the technical component, and PVA would bill for the professional component.

Factual Allegations in Montcrieff

The Relators alleged that PVA engaged in two practices that violate the False Claims Act.  First, they alleged that PVA billed for services before they were complete.  In other words, the Relators’ claim that PVA employed a scheme of “too-quick” billing in order to increase revenue.  What PVA would do, according to the Relators, was bill Medicare for both the technical and professional components before a PVA doctor completed the professional component – the review of the ultrasound results.

Second, the Relators alleged that PVA would bill Medicare for vascular ultrasound services, both components, even though the patient had yet to be seen by a PVA doctor.  That meant that, if true, PVA would bill for an ultrasound, even though no physician had yet to order that ultrasound.

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