COLUMBIA, S.C. — South Carolina's largest urgent care provider, Doctors Care, and its management company UCI Medical Affiliates of South Carolina have been found in violation of the federal False Claims Act and have been fined $22.5 million in restitution.
The charges stem from an investigation that began as a whistleblower complaint alleging Doctors Care, UCI, and UCI Medical Affiliates, Inc. (a related holding company), falsely certified that certain urgent care visits were performed by providers who were credentialed (authorized) to bill Medicaid, Medicare, and TRICARE for medical services when, in fact, the providers were not credentialed.
Federal health insurance companies -- Medicaid, Medicare, and TRICARE -- require physicians and mid-level providers such as Doctors Care to apply for and receive approval to bill any services to the insurer. This approval is known as a provider’s “billing credentials.” Providers are obligated to renew these billing credentials periodically and must obtain new credentials with new employment.
Billing credentials are different from a provider's medical degree or license to practice medicine. There is no evidence to show that Doctors Care providers lacked medical licenses or that patient care was compromised due to the conduct at issue. The conduct at issue is one of billing and insurance fraud, not health care.
The investigation found that as early as 2013 and continuing to 2018, UCI allegedly was unable to secure and maintain necessary billing credentials for most Doctors Care providers in South Carolina. UCI knew that the federal health insurance companies would deny claims submitted by uncredentialed providers but rather than solving the problem, UCI allegedly submitted the claims falsely by "linking" uncredentialed providers to credentialed providers in order to get the claims paid.
Each "linked" bill submitted by UCI is alleged to be a false claim for payment. Evidence obtained in support of the allegations includes emails memorializing UCI’s “linking” scheme and well-organized “cheat sheets,” as employees called them, which UCI used to keep track of properly-credentialed billing providers whose names could be substituted on uncredentialed providers’ bills.
The settlement of $22.5 million in the case of United States ex. rel. Dove v UCI Medical Affiliates, Inc, et. al, 2:17-cv-02291-RMG (D.S.C.) is the result of over three years of investigation, led by the United States Attorney’s Office in coordination with the HHS-OIG and DCIS. Upon receiving the first investigative subpoena in early 2018, management for UCI and Doctors Care acted promptly to investigate and stop the conduct subject to this settlement.
In addition to the monetary settlement, UCI and Doctors Care also entered into a Corporate Integrity Agreement with the Office of Inspector General. Among other things, the Corporate Integrity Agreement requires that for the next five years UCI must retain an Independent Review Organization to perform a claims review in accordance with the specific requirements of the Corporate Integrity Agreement, and it requires that UCI routinely be monitored by the Office of Inspector General.