The Medical Center of Southeastern Oklahoma, located in Durant, Oklahoma, and its parent, Health Management Associates, Inc., have agreed to pay $1,065,000 to the United States and $435,000.00 to the State of Oklahoma to resolve allegations that the hospital billed SoonerCare, the Oklahoma Medicaid Program, for surgical procedures performed by Dr. Daniel Castro, and related hospital services, that were not medically necessary, the United States Attorney’s Office for the Eastern District of Oklahoma announced today. The settlement also resolves claims that the hospital billed for services related to surgical procedures that Castro did not perform. In January of this year, HMA was acquired by Community Health Systems, a nationwide acute care hospital chain. MCSO is an acute care hospital in Durant, Oklahoma, and Dr. Castro is an otolaryngologist who practiced at MCSO from 2005 to 2010.
Mark Green, United States Attorney for the Eastern District of Oklahoma, stated: “Health Care Fraud is a tremendous problem in Eastern Oklahoma as well as across the nation. Fraud, such as billing for services that aren’t necessary, costs the taxpayers of Oklahoma thousands of 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 MCSO submitted claims to SoonerCare for surgical procedures performed by Dr. Castro, and related hospital services that were not medically necessary. The surgical procedures in question were functional endoscopic sinus surgeries (FESS) performed by Dr. Castro on children who were SoonerCare beneficiaries. According to the United States, Dr. Castro performed FESS’s on children that were not medically indicated, and Dr. Castro and the hospital billed SoonerCare for the unnecessary surgeries and related hospital services. The settlement also resolves claims that MCSO billed SoonerCare for hospital services related to FESS’s that Dr. Castro did not actually perform.
The allegations that the government has settled with MCSO 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 $159,750 as part of today’s settlement.
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 Attorney General Eric Holder and Health and Human Services Secretary Kathleen Sebelius. 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 $19 billion through False Claims Act cases, with more than $13.6 billion of that amount recovered in cases involving fraud against federal health care programs.
This case was a coordinated effort among the United States Attorney’s Office for the Eastern District of Oklahoma, the Civil Division of the United States Department of Justice, the Office of the Inspector General of the Department of Health and Human Services and the Office of the Oklahoma Attorney General. The lawsuit is captioned United States ex rel. Sandra Simmons v. Health Management Associates, Inc., Durant H.M.A., LLC d/b/a Medical Center of Southeastern Oklahoma, Durant HMA Physician Management, LLC and Dan J. Castro, M.D., Case No. CIV-12-043-JHP (E.D. Okla.).
Assistant United States Attorneys Susan S. Brandon and Robert Gay Guthrie are assigned to the case.
The claims settled or pursued by the government are allegations only; there has been no determination of liability.