On June 11, 2018, James S. Dunn, Jr., MD, d/b/a Auburn Urogynecology and Women’s Health (collectively, “Dr. Dunn”), Auburn, California, entered into a $419,578 settlement agreement with OIG. The settlement agreement resolves allegations that Dr. Dunn submitted claims to Medicare for items or services that he knew or should have known were not provided as claimed or were false or fraudulent. Specifically, OIG contended that Dr. Dunn submitted claims for:

  1. diagnostic electromyography services using CPT Code 51784 and diagnostic anorectal manometry using CPT Code 91122 when therapeutic, not diagnostic, services had been provided;
  2. pelvic floor electrical stimulation that was not preceded by a four-week course of failed pelvic muscle exercise training; and
  3. pelvic floor physical therapy services that were provided by an unqualified individual.

It was reported that the OIG’s Consolidated Data Analysis Center collaborated on this settlement which might mean the issues were identified through data analytics.

Compliance officers reading these summaries can see how implementing some of the best practices of an effective compliance program might have been able to prevent these problems. For example, regular performance of exclusion checks might have identified the excluded individuals employed by some of the organizations which some of the billing and claims issues might have been identifiable through regular auditing and monitoring programs.