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By its terms, the False Claims Act provides, inter alia, that: Any person who--(1) knowingly presents, or causes to be presented, to [the Government] . . . a false or fraudulent claim for payment or approval;(2) knowingly makes, uses, or causes to be made or used, a false record or statement to get a false or fraudulent claim paid or approved by the Government;(3) conspires to defraud the Government by getting a false or fraudulent claim allowed or paid;. . .is liable to the United States Government for a civil penalty of not less than $ 5,000.00 and not more than $ 10,000.00, plus three times the amount of damages which the Government sustains because of the act of that person. . . .31 U.S.C. § 3729(a).
On January 11, 1993, the United States filed this civil suit against George O. Krizek, M.D. and Blanka H. Krizek under the False Claims Act, 31 U.S.C. §§ 3729-3731, and at common law. The government brought the action against the Krizeks' alleging false billing for Medicare and Medicaid patients. The government alleged two types of misconduct related to the submission of bills to Medicare and Medicaid. The first category of misconduct related to the use of billing codes found in the American Medical Association's "Current Procedural Terminology" ("CPT"), a manual that lists terms and codes for reporting procedures performed by physicians. The government alleged that Dr. Krizek "up-coded" the bills for a large percentage of his patients by submitting bills coded for a service with a higher level of reimbursement than that which Dr. Krizek provided. As a second type of misconduct, the government alleged Dr. Krizek "performed services that should not have been performed at all in that they were not medically necessary." Given the large number of claims, and the acknowledged difficulty of determining the "medical necessity" of 8,002 reimbursement claims, it was decided that this case should initially be tried on the basis of seven patients and two hundred claims that the government believed to be representative of the Dr. Krizek's improper coding and treatment practices.
Was Dr. Krizek justified in seeing patients and later not verifying the claims submitted for the services provided to these patients?
The court found that Dr. Krizek did submit claims when he did not provide patient services for the amount of time that was billed. The court also found that Dr. Krizek and his billing clerk acted with reckless disregard as to the truth or falsity of the submissions, and their conduct constituted a violation of the Act. The court issued an injunction that enjoined Dr. Krizek and his billing clerk from participating in Medicare and Medicaid until they could show the court that they could abide by the relevant rules.