Suffield Doctor Pays $379,764 to Settle Allegations Under the False Claims Act

David B. Fein, United States Attorney for the District of Connecticut, today announced that WILLIAM J. GARRITY, D.O. (d/b/a Suffield Primary Care and d/b/a Family Medicine), a doctor of osteopathic medicine with a practice located at 230B Mountain Road in Suffield, has entered into a civil settlement agreement with the government in which he will pay $379,764 to resolve allegations that he violated the False Claims Act.

U.S. Attorney Fein explained that the allegations against GARRITY involved improper billing to Medicare for evaluation and management services (also known as office visits) that were not medically necessary or were not provided. Much of GARRITY’s practice involved treating patients using osteopathic manipulative treatment (OMT), a medical procedure used by osteopathic physicians to treat musculoskeletal disorders. Data analysis of GARRITY’s practice indicated that approximately 95 percent of the time that he billed Medicare for OMT, he also billed Medicare for an evaluation and management service, using a special billing modifier (Modifier 25), which allowed payment for both the OMT procedure and the evaluation and management service on the same day.

Medicare does not normally allow additional payments for evaluation and management services performed by a provider on the same day as a procedure because it is expected that most procedures involve some pre-procedure and post-procedure care that is part of the payment for that procedure.  However, if a provider performs an evaluation and management service on the same day as a procedure that is significant, separately identifiable, and above and beyond the usual pre-procedure and post-procedure care associated with the procedure, Modifier 25 may be attached to the claim to allow additional payment for the separate evaluation and management service.

The government alleges that GARRITY improperly submitted claims with Modifier 25 in order to receive payments for both OMT services and evaluation and management services on the same day for the same Medicare patients. The government further alleges that a review of GARRITY’s medical records has revealed that there was often was no documentation of a significant, separately identifiable reason for the patient’s visit (i.e., the patient was there only for regularly scheduled OMT services); there was often no documentation of the medical necessity for the evaluation and management services; and there was often no documentation that evaluation and management services had been performed at all.

“Gaming the Medicare reimbursement system depletes the government’s health care resources,” stated U.S. Attorney Fein. “Health care fraud is a serious national problem that the United States Attorney’s Office is committed to combating here in Connecticut.”

To resolve his liability under the False Claims Act, GARRITY will pay $379,764 in order to reimburse the Medicare program for conduct occurring between 2002 and 2009.

The False Claims Act provides for treble damages and penalties of $5,500 to $11,000 per false claim submitted to the government.

As part of the settlement, GARRITY has entered into a five-year billing integrity agreement with the U.S. Department of Health and Human Services that is designed to ensure future compliance with the requirements of the Medicare program.

In entering into the civil settlement agreement, GARRITY did not admit liability.

This case was investigated by the Office of Inspector General for the Department of Health and Human Services and the Federal Bureau of Investigation, and was prosecuted by Assistant United States Attorney Richard M. Molot, along with Auditor Kevin A. Saunders.

People who suspect health care fraud are encouraged to report it by calling 1-800-HHS-TIPS or the Health Care Fraud Task Force at (203) 785-9270.