Medicare Compliance & Reimbursement

Alleging a higher-level service than you actually perform results in a false claim — and for a Spokane-area cardiologist that translates to a $300,000 settlement due back to the Feds.

In a case that explains the OIG’s need for Comparative Billing Reports (CBRs), Washington cardiologist, Dr. Romeo Pavlic, conducted “cardiac clinics” at Lakeland Village in Medical Lake, a facility devoted to the care of adults with severe physical and mental disabilities. During his short visits, the physician would schedule patients in 5- to 10-minute intervals, seeing as many as 55 residents over a three-hour time span. The unusually heavy load of patients in such a short time alerted the OIG to his odd behavior, but his claims data sealed his fate.

While attending to his patients, he often billed Medicare and Medicaid for a “complete echocardiogram when in fact he was only providing a limited echocardiogram,” a Department of Justice release said. Claims data showed that Pavlic billed complete EKGs in 90 percent of his claims in comparison to his local peers, who billed the same service 12 percent of the time. Despite a warning about his outlier behavior in December of 2012, he continued to send false claims to CMS.

On March 16, he settled with the federal government and the state of Washington for a total of $300,000 — $279,190 to the U.S. and $20,810 to the State of Washington for its portion of the Medicaid payments — to be paid within five days.

“When doctors exploit vulnerable patients and bill for procedures that were never performed, they violate the basic trust that patients and taxpayers extend to healthcare providers,” said Special Agent in Charge Steven J. Ryan, of the HHS OIG. “We will continue to aggressively pursue those who engage in health care fraud.”

To read the DOJ release, visit www.justice.gov/usao-edwa/pr/spokane-area-cardiologist-dr-romeo-pavlic-pay-300000-resolving-alleged-false-health.