Hawks v. Heart & Vascular Institute of Florida et al

Middle District of Florida, flmd-8:2016-cv-01574

COMPLAINT against Heart & Vascular Institute of Florida, Irfan Siddiqui with Jury Demand Filing fee $ 400.00, receipt number TPA-37363 filed by Lois Hawks.

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0 PageID 1 UNITED STATES DISTRICT COURT MIDDLE DISTRICT OF FLORIDA ! ! ! ' . CASE NO .: UNITED STATES OF AMERICA, ex rel. LOIS HAWKS, Plaintiff, wuuuuuuu - jь су15ay Tзете VS. UNDER SEAL HEART & VASCULAR INSTITUTE OF FLORIDA, a Florida Professional Liability Company, and IRFAN SIDDIQUI, D. O. Individually, Defendant. COMPLAINT Plaintiff and Relator, Lois Hawks ("Relator"), brings this civil action to recover damages and civil penalties on behalf of the United States of America and against Heart & Vascular Institute of Florida, PLC, and Irfan Siddiqui, D. O. This action arises from the false statements and false claims made and presented, and caused to be made and presented, by the Defendants in violation of the Federal False Claims Act, 31U.S. C. § 3729, et seq ., as amended (the " Act") as a result of the scheme. Relator brings this action for violations of 31U.S. C. § 3729, et seq ., on behalf of herself and the United States Government and its agency, the United States Department of Health and Human Services ("HHS), Centers for Medicare and Medicaid Services ("CMS " and / or " Medicare"), pursuant to 31U.S. C. § 3730 (b) (1) . Relator has direct and personal knowledge that the Defendants have engaged in a scheme to submit false claims to the Medicare program NICHOLSON & FASTIN. LLP 707 N. E. THIRD AVENUE, SUITE 301, FORT LAUDERDALE, FLORIDA 33304 TRA _ 37363 $ 400 0 PageID 2 for medically unnecessary, upcoded and / or non - reimbursable services provided to Medicare beneficiaries. As required under the False Claims Act, 31U.S. C. § 3730 (b) (2), the Relator has provided to the Government a statement of substantially all material evidence and information related to this complaint currently in Relator's possession. This disclosure statement supports the existence of the submission of knowingly false or fraudulent claims for payment or approval, as well as the knowing, making, using, and causing to be made and used, false records or statements material to a false or fraudulent claim under the False Claims Act, in violation of 31U.S. C. $ 8 3729 (a) (1) (A) and (B) . INTRODUCTION 1. This is an action involving the routine submission of false claims to Medicare for reimbursement stemming from the provision of medically unnecessary, upcoded, and / or non reimbursable services for Medicare beneficiaries, which the Defendants made and caused to be made to Medicare from at least October 14, 2014, to in or around April 2015. The Defendants knew such claims were false and / or ineligible for reimbursement when submitted, or the Defendants submitted and caused to be submitted such claims in reckless disregard for the falsity of the claims and statements submitted, and in reckless disregard for the lack of eligibility for payment of the claims submitted. 2. The Relator in this matter is a former patient of Dr. Siddiqui and Heart & Vascular Institute of Florida and has personal knowledge regarding the False Claims Act scheme alleged herein. Specifically, Relator Lois Hawks was referred to Dr. Siddiqui by her podiatrist for evaluation and treatment of pain and redness in her left ankle. As discussed more fully infra, Ms. Hawks was a patient of Dr. Siddiqui's from October 14, 2014, to in or around April 2015, NICHOLSON & FASTIN. LLP 707 N. E. THIRD AVENUE, SUITE 301. FORT LAUDERDALE, FLORIDA 33304 0 PageID 3 during which time she was treated for superficial and perforating veins by endovenous radiofrequency ablation. 3. The Act provides that any person who knowingly submits or causes to be submitted a false or fraudulent claim to the Government for payment or approval is liable for a civil penalty of up to $ 11, 000 for each such claim submitted or paid, plus three times the amount of the false claims submitted to the Government. The Act allows any person having information regarding a false or fraudulent claim against the Government to bring an action for him or herself (the " relator") and for the Government and to share in any recovery. 4. Based on those provisions, the Relator in this case seeks to recover damages and civil penalties arising from the Defendants ' presentation of false records, false claims, and false statements to the United States Government and its agents in connection with Defendants ' claims ve for reimbursement for medically unnecessary, upcoded, non - rendered, and / or non - reimbursable services provided to beneficiaries under the Medicare program. JURISDICTION AND VENUE 5. This Court has jurisdiction over the subject matter of this action pursuant to 28U.S. C. § 1331, 28U.S. C. § 1345, and 31U.S. C. 8 3732, which specifically confer jurisdiction on this Court for actions brought pursuant to 31U.S. C. $ $ 3729 and 3730. 6. This Court has personal jurisdiction over the Defendants pursuant to 31U.S. C. S 3732 (a), which provides that, " [ a ] ny action under section 3730 may be brought in any judicial district in which the defendant, or in the case of multiple defendants, any one defendant can be found, resides, transacts business or in which any act proscribed by section 3729 occurred. " Id. Section 3732 (a) also authorizes nationwide service of process. During the relevant period, the Defendants resided in and / or transacted business in the Middle District of Florida. NICHOLSON & EASTIN, LL. P 707 N. E. THIRD AVENUE, SUITE 301, FORT LAUDERDALE, FLORIDA 33304 0 Pageld 4 7. Venue is proper in the Middle District of Florida pursuant to 28U.S. C. § 1391 (b) and 31U.S. C. § 3732 (a) because the Defendants can be found in, reside in, and or transact business within this district. PARTIES 8. Defendant Heart & Vascular Institute of Florida is a Florida limited liability company that was registered with the Florida Secretary of State on November 8, 2011, with a principal place of business of 405 Lionel Way, Davenport, Florida 33837. The registered agent for the company is Irfan Siddiqui, D. O. Heart & Vascular Institute has a NPI number of 1598042822, and it submits claims to Medicare under that number. 9. Heart & Vascular Institute specializes in cardiology and vascular medicine and recognizes itself as " Florida's cardiac care leader. " Relevant here, Heart & Vascular Institute provides endovenous ablation for treatment of varicose veins, among other things. 10. Defendant Irfan Siddiqui, D. O ., is the Managing Member and registered agent of Heart & Vascular Institute of Florida, the entity which has submitted the false claims and false statements to Medicare. Dr. Siddiqui is a doctor of osteopathic medicine specializing in cardiology and is certified to diagnose and treat disorders of the circulatory and cardiovascular system. Upon information and belief, Dr. Siddiqui is a resident of Polk County, Florida. Dr. Siddiqui is a knowing participant in the scheme to submit false claims to Medicare, and to create false statements and records material to the submitted false claims. Dr. Siddiqui has a NPI number of 1063548097, and he submits claims to Medicare through his group practice, Heart & Vascular Institute. As described herein, the Defendants engaged in a coordinated and collaborative effort to generate and submit false claims and documents to the Medicare Program for their financial benefit. NICHOLSON & FASTIN. I. LV 707 N. E. THIRD AVENUE, SUITE 301. FORT LAUDERDALE, FLORIDA 33304 0 Pageld 5 11. Relator Lois Hawks, is a resident of Florida, and a former patient of Heart & Vascular Institute and Dr. Siddiqui. The scheme alleged herein was personally witnessed by Relator Lois Hawks from October 14, 2014, to in or around April 2015, during which time Dr. Siddiqui submitted claims for upcoded evaluation and management services and ordered Ver medically unnecessary endovenous radiofrequency ablation treatments, which were performed by unqualified staff and which caused severe numbness and pain in Ms. Hawks leg, which still persists today. Sometime thereafter, Ms. Hawks became aware that Dr. Siddiqui falsified information in her medical records to support the upcoded claims and the medically unnecessary services he was ordering. 12. The United States of America is named as a Plaintiff because funds of the United States of America were and are being paid to Defendants as a result of the false claims scheme alleged in this complaint. The United States is the true party in interest in this litigation. GENERAL ALLEGATIONS A. Medicare and Reimbursement 13. Medicare is a federally - funded health insurance program for the elderly and the disabled. Medicare was created in 1965 in Title XVIII of the Social Security Act and is codified at 42U.S. C. § 301 et seq. Medicare is administered by CMS and is funded through HHS. 14. Claims submitted to Medicare for reimbursement must satisfy the requirements of the Social Security Act, as well as applicable regulations, procedures, and instructions. Providers participating in Medicare are required to familiarize themselves with all applicable laws, regulations, procedures, and instructions and to certify on each claim that it is being submitted in full compliance with governing law. Federal regulations also require providers to NICHOLSON & EASTIN, LLP 707 N. E. THIRD AVENUE. SUITE 301, FORT LAUDERDALE, FLORIDA 33304 0 PageID 6 furnish CMS, through its intermediaries, all information necessary to assure proper payment under the Medicare program. 15. Medicare has multiple " parts. " For example, Medicare Part A, the Basic Plan of Hospital Service, covers the cost of hospital and related ancillary services, such as home health agencies and skilled nursing facilities. Medicare Part B covers the cost of physician services and related ancillary services. Generally, no payments may be made under the Medicare program for expenses incurred for items and services, including drugs, that are not " reasonable and necessary " for the diagnosis and treatment of an illness or injury. See, 42U.S. C. $ 1395y (a) (1) (A) . 16. CMS issues national coverage determinations ("NCDs") that specify whether certain items, services, procedures or technologies are " reasonable and necessary " under $ 1862 (a) (1) (A) of the Act. 17. In the absence of or in addition to a NCD, CMS's regional fiscal intermediaries known as Medicare Administrative Contractors ("MACS") are responsible for creating and implementing Local Coverage Determinations ("LCDs") . A LCD, as defined by the Social Security Act, " means a determination by a fiscal intermediary or a carrier under part A or part B, as applicable, respecting whether or not a particular item or service is covered on an intermediary or carrier - wide basis under such parts, in accordance with section § 1862 (a) (1) (A) . " See Section $ 1869 (1) (2) (B) of the Social Security Act. 18. At all times relevant to this complaint, Medicare contracted with multiple entities to process claims for medical services and treatment. Relevant here, First Coast Service Options (hereinafter " FCSO"), which is the regional contractor for the Southeast United States, was and is responsible for processing and payment claims, as well as publishing LCDs regarding NICHOLSON & EASTIN, LLP 707 N. E. THIRD AVENUE. SUITE 301. FORT LAUDERDALE, FLORIDA 33304 0 Pageld 7 coverage criteria and documentation requirements for certain services, such as those at issue in this case. Heart & Vascular Institute and Dr. Siddiqui were required to and did submit Medicare claims for payment to FCSO for the services provided to Medicare beneficiaries. FCSO would then request payment from the United States on behalf of Defendants and forward payment to Heart & Vascular Institute. B. Evaluation and Management Services 19. Evaluation and management codes ("E / M") are use to report evaluation and management services provided in the office or in an outpatient or other ambulatory facility. See CPT Code Book, Professional Edition, American Medical Association (2014) . The specific CPT code billed is dependent on whether he / she is a new or established patient. A new patient is one who has not received any professional services from the physician / qualified health care professional or another physician / qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years, while an established patient has not. Here, professional services are defined as those face - to - face services rendered by physicians and other qualified health care professionals who may report E / M services reported by a specific CPT code. Id. 20. " Medical necessity of an E / M service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. " See Medicare Claims Processing Manual, Ch. 12 - Physicians / Nonphysician Practitioners. NICHOLSON & EASTIN, LLP 707 N. E. THIRD AVENUE, SUITE 301, FORT LAUDERDALE, FLORIDA 33304 0 PageID 8 21. CPT Code 99204: Office or other outpatient visit, is billed " for the evaluation and management of a new patient, which requires these 3 key components: a comprehensive history; Nr a comprehensive examination; medical decision making of moderate complexity. " See CPT Code Book, Professional Edition, American Medical Association (2014) . Typically CPT Code 99204 is billed when the presenting problem (s) are of moderate to high severity and 45 minutes are spent face - to face with the patient and / or family. Id. 22. Ms. Hawks first presented to Heart & Vascular Institute and Dr. Siddiqui on October 14, 2014, pursuant to a referral from her podiatrist for evaluation and treatment of pain and redness in her right ankle. During this visit, Ms. Hawks complained of general bilateral pain in her legs, including cramping. Dr. Siddiqui did not perform any type of examination and spent no more than approximately five (5) minutes with Ms. Hawks before ordering a series of ultrasounds in advance of the Endovenous Radiofrequency Ablation ("RFA") . In fact, Ms. Hawks questioned Dr. Siddiqui why he was not physically examining her to which he responded, " I can see you have a problem from here. " Contrary to the entries by Dr. Siddiqui in her medical records, Ms. Hawks had no complaints of leg swelling, edema, or discoloration of the legs, and she had no burning sensation, tingling, or numbness. A copy of the original October 14, 2014, office note is attached as Exhibit 1 (note that the date on the Exhibit is incorrectly identified as April 14, 2015) . 23. Moreover, the medical records identified several diagnoses that Ms. Hawks did not have including: angina pectoris NEC NOS (ICD - 9 413. 9), mixed hyperlipidemia (ICD - 9 272. 2), hypertension benign essential (ICD - 9 401. 1), and shortness of breath (ICD - 9 786. 05), among others. Dr. Siddiqui submitted a claim for this office visit using CPT Code 99204, identified by Claim No. 1014289372710, a copy of which is included in composite Exhibit 2. As NICHOLSON & EASTIN, LLP 707 N. E. THIRD AVENUE, SUITE 301. FORT LAUDERDALE, FLORIDA 33304 0 PageID 9 discussed more fully infra, Dr. Siddiqui falsified these office notes to substantiate the more complex E / M visit, to support medical necessity for the RFA treatments, and to increase reimbursement. 24. CPT Code 99214: Office or other outpatient visit, is billed " for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity. " See CPT Code Book, Professional Edition, American Medical Association (2014) . Typically CPT Code 99214 is billed when the presenting problem (s) are of moderate to high severity and 25 minutes are spent face - to face with the patient and / or family. Id. 25. After a series of ultrasounds, Ms. Hawks had another office visit with Dr. Siddiqui on November 25, 2014. As with the initial visit, Dr. Siddiqui did not perform any type of examination and spent no more than approximately ten (10) minutes with Ms. Hawks and her husband. Dr. Siddiqui submitted a claim for this office visit using CPT Code 99214, identified by Claim No. 1014330616830, a copy of which is included in composite Exhibit 2. Dr. Siddiqui upcoded this E / M service in order to increase reimbursement. 26. On January 6, 2015, Ms. Hawks had another office visit with Dr. Siddiqui after one ablation treatment. As with the prior two visits, Dr. Siddiqui did not perform any type of examination and spent no more than approximately five (5) minutes with Ms. Hawks. Dr. Siddiqui submitted a claim for this office visit using CPT Code 99214, identified by Claim No. 1915020667790, a copy of which is included in composite Exhibit 2. Dr. Siddiqui upcoded this E / M service in order to increase reimbursement. 27. After two (2) additional ablation treatments and several ultrasounds, Ms. Hawks had another office visit with Dr. Siddiqui on March 17, 2015. As with the prior two visits, Dr. NICHOLSON & EASTIN, LLP 707 N. E. THIRD AVENUE, SUITE 301, FORT LAUDERDALE, FLORIDA 33304 0 PageID 10 Siddiqui did not perform any type of examination even though Ms. Hawks complained of severe pain in her lower right leg following the most recent ablation treatment. More specifically, Ms. Hawks informed Dr. Siddiqui, who had not performed the RFA, that she had complained during the RFA procedure of a burning sensation and that following the procedure her lower right leg was numb and painful. As a result of her complaints. Dr. Siddiqui ordered physical therapy for Ms. Hawks. Upon information and belief, Ms. Hawks would not have needed physical therapy if the RFA had been performed by a qualified physician. Although Dr. Siddiqui again spent approximately ten (10) minutes with Ms. Hawks, he submitted a claim for this office visit using CPT Code 99214, identified by Claim No. 1015082766600, a copy of which is included in composite Exhibit 2. Dr. Siddiqui upcoded this E / M service in order to increase reimbursement. 28. CPT Code 99213: Office or other outpatient visit, is billed " for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity. " See CPT Code Book, Professional Edition, American Medical Association (2014) . Typically CPT Code 99213 is billed when the presenting problem (s) are of low to moderate severity and 15 minutes are spent face - to face with the patient and / or family. Id. 29. After completing her physical therapy, Ms. Hawks followed up with Dr. Siddiqui on April 14, 2015, and complained that she was still experiencing numbness in her right leg. Unlike the prior visits, Dr. Siddiqui performed a very limited examination, specifically Dr. Siddiqui listened to Ms. Hawks heart, lungs, and carotids and stated " you are just fine. " Dr. Siddiqui spent no more than approximately five (5) minutes with Ms. Hawks. Dr. Siddiqui submitted a claim for this office visit using CPT Code 99213, identified by Claim No. NICHOLSON & FASTIN. LLP 707 N. E. THIRD AVENUE, SUITE 301. FORT LAUDERDALE, FLORIDA 33304 10 0 Pageld 11 1015107699050, a copy of which is included in composite Exhibit 2. Dr. Siddiqui upcoded this E / M service in order to increase reimbursement. 30. Ms. Hawks did not follow - up with Dr. Siddiqui after completing her physical therapy even though she continued to experience severe pain in her lower right leg. As discussed more fully below, Ms. Hawks scheduled one final appointment with Dr. Siddiqui in February 2016, after discovering the false information he put in her medical records, during which she confronted Dr. Siddiqui regarding the false information. Dr. Siddiqui explained that he uses " a template for this type of diagnosis, " and that " varicose veins usually [ have ] one or more of these underlying causes, " and if he doesn ' t " use those diagnosis he would have a lot of people mad at him because Medicare would not pay the bill. " Dr. Siddiqui ultimately acknowledged that the information was false and agreed to Ms. Hawks ' demand that he remove the false complaints, evaluation, and diagnoses. 31. Based upon Dr. Siddiqui's admission to Ms. Hawks, it is evident that Dr. Siddiqui routinely upcoded E / M services for his patients in order to support medically unnecessary services, such as diagnostic testing and RFA, and to increase reimbursement. C. Endovenous Radiofrequency Ablation 32. RFA is a minimally invasive alternative to surgical intervention, including high ligation and saphenous vein stripping ("HL / S"), for treatment of superficial and perforating veins that can be performed in an office / outpatient setting using local anesthesia. See L28999: Treatment of varicose veins of the lower extremity, First Coast Service Options, a copy of which is attached as Exhibit 3. Superficial and perforating venis, also known as varicose veins, are visible distended superficial veins greater than 3 mm with venous incompetence which may not require treatment and therefore would not be a covered Medicare benefit. NICHOLSON & FASTIN, LL. 1 707 N. E. THIRD AVENUE, SUITE 301. FORT LAUDERDALE, FLORIDA 33304 Case 8: 16 - cv - 01574 - CEH TGW Document 1 Filed 06 / 15 / 16page 12 of 20 PageID 12 33. During this treatment, the endothelium of the vein is damaged, which results in fibrosis and occlusion of a vein segment in order to eliminate reflux. In layman's terms, RFA closes off the problem veins through intense local heat directed through a catheter to the targeted vessel. The benefits of RFA including minimal bleeding and bruising, as well as less pain and faster return to normal activities, 34. RFA is billed using CPT Code 36475, and each treatment currently reimburses at $ 1527. 07. Each RFA treatment takes approximately 45 - 60 minutes, and in many cases, multiple treatments on separate days are necessary during a 90 - day episode of care. 35. RFA is only medically indicated and " reasonable and necessary " for certain classifications of chronic venous disorders which are based on the clinical severity, etiology, anatomy, and pathophysiology ("CEAP") of the patient. Id. " The evaluation of a patient with lower extremity venous incompetence and its advanced consequences – edema and skin changes — should include the assessment of history and physical examination including the CEAP classification and revised Venous Clinical Severity Score (VCSS), " which must be supported by " duplex ultrasound scan of the deep and superficial venous systems. " Id. 36. For patients with a " clinical severity " score of C3 - C6, documentation must include signs such as thickening and discoloration, superficial phlebitis, edema, variceal hemorrhage, and ulceration, as well as a duplex ultrasound scan report demonstrating saphenous vein reflux (at least 500 ms) and a GSV (great saphenous vein) diameter of at least 5 mm and SSV (small saphenous vein) diameter of at least 3 mm. Id. 37. Moreover, in certain instances, conservative therapy must be attempted prior to performing any procedure. Conservative therapy refers to the nonsurgical management of varicose veins which includes leg elevation, weight management for the overweight and obese, NICHOLSON & EASTIN, LL. P 707 N. E. THIRD AVENUE, SUITE 301. FORT LAUDERDALE, FLORIDA 33304 12 0 Pageld 13 and the use of graduated compression stockings or wraps. According to FCSO, " compression therapy is an important adjunct for patients with advanced signs of venous insufficiency especially those with edema, skin changes, and venous stasis ulcers (C3 - C6) . " Id. 38. The medical necessity for RFA must be supported in the plan of care. The plan of care is based on the treating physician's assessment with CEAP and VCSS classification including the date (s) of exam and diagnostic evaluation, which includes a history, physical exam, and a formal venous duplex ultrasound scan. The plan of care must further describe the specific procedure (s) to be used in a 90 - day episode of care consistent with the CEAP and VCSS classification and supporting clinical and diagnostic data. Id. 39. Here, Dr. Siddiqui failed to perform any physical evaluation of Ms. Hawks during her initial visit prior to concluding RFA was an appropriate and medically necessary treatment option. Dr. Siddiqui falsely represents in his medical record that " [ C ] onservative medical treatment for varicose veins [ was) attempted, " specifically that the " [ P ] atient was treated with support stockings at 20 - 30mmHG for 3 - 6 months with partial improvement. " This is blatantly false, as Dr. Siddiqui never suggested a conservative treatment to Ms. Hawks. 40. As previously discussed, Dr. Siddiqui also identified several false symptoms and diagnoses which he admitted " had " to be included in order for Medicare to pay for " the services and to avoid upsetting Medicare beneficiaries with bills for non - covered services. Based on these false symptoms and diagnoses, Dr. Siddiqui documented Ms. Hawks CEAP score as C4b, which was purportedly confirmed by ultrasound. 41. Based upon Dr. Siddiqui's admissions, it is evident that Dr. Siddiqui routinely ordered RFA for patients: who were not thoroughly evaluated and for whom conservative therapy was not attempted; who did not meet the required coverage criteria; for whom RFA was NICHOLSON & EASTIN, LLP 707 N. E. THIRD AVENUE, SUITE 301, FORT LAUDERDALE, FLORIDA 33304 0 PageID 14 not medically necessary; and for whom it was not " reasonable and necessary " as required by CMS. Thus, Dr. Siddiqui routinely falsified records in order to establish medical necessity for the RFA treatments. 42. Additionally, to be properly billable and reimbursable, these services must be performed by appropriately trained providers. See CMS Manual System, Pub. 100 - 8, Program Integrity Manual, Chapter 13, Section 5. 1. " A qualified physician for this service / procedure is defined as follows: A) Physician is properly enrolled in Medicare. B) Training and expertise must have been acquired within the framework of an accredited residency (general or vascular surgery, radiology, cardiology) and / or fellowship program in the applicable specialty / subspecialty in the United States or must reflect equivalent education, training, and expertise endorsed by an academic institution in the United States or by the applicable specialty / subspecialty society in the United States. See id. Critical here, " ultrasound technologists and therapists do not qualify to surgically treat varicose veins. " Id. (emphasis added) . 43. Heart & Vascular Institute and Dr. Siddiqui failed to meet this requirement by allowing unqualified non - physician practitioners to perform the RFA procedures. More specifically, Ms. Hawks received three (3) RFA treatments, none of which were performed by Dr. Siddiqui or another qualified physician, and were apparently performed by a technician. Dr. Siddiqui submitted claims for these treatments using CPT Code 36475, identified by Claim Nos. 1114356160560, 1915020667320, and 1015071692180, copies of which is included in composite Exhibit 4. As a result, during the third and final ablation procedure in March 2015, Ms. Hawks complained of an intense burning sensation, but the procedure was not aborted. Ms. Hawks thereafter began experiencing severe numbness and pain in that leg, and the numbness NICHOLSON & FASTIN. LLP 707 N. E. THIRD AVENUE. SUITE 301. FORT LAUDERDALE, FLORIDA 33304 14 Case 8: 16 - cv - 01574 - CE HT GW Document 1 Filed 06 / 15 / 16mfage 15 of 20 Pageld 15 still persists today. Even though he did not provide the service, the claim forms for each of RFA procedures falsely identified Dr. Siddiqui as the rendering provider. 44. In order to address Ms. Hawks ' complaints of severe numbness and pain in her leg caused by complications of the final RFA procedure, Ms. Hawks was directed to physical therapy. Upon information and belief, the physical therapy would not have been necessary if the RFA procedures had been properly performed by a qualified physician. 45. During her initial therapy evaluation, Ms. Hawks became aware that Dr. Siddiqui had falsified information in her medical records. More specifically, her physical therapist allowed Ms. Hawks to review her file, and Ms. Hawks was shocked to learn that Dr. Siddiqui had diagnosed her with multiple false diagnoses, as well as documenting purported failed COM conservative treatments, which Dr. Siddiqui never ordered and Ms. Hawks never tried. 46. As previously discussed, Ms. Hawks confronted Dr. Siddiqui in February 2016, regarding the falsities in her records. Dr. Siddiqui explained that he uses " a template for this type of diagnosis, " and that " varicose veins usually [ have ] one or more of these underlying causes, " and if he doesn ' t " use those diagnosis he would have a lot of people mad at him because Medicare would not pay the bill. " After acknowledging all of the falsities in the records, Dr. Siddiqui removed them. He refused, however, to notify Medicare of the changes because he said that " money could be due. " A copy of the corrected medical record dated February 23, 2016, is attached as Exhibit 5. Thus, Dr. Siddiqui is also knowingly retaining an overpayment due to Medicare. D. Duplex Ultrasound Scans 47. A duplex scan is a non - invasive vascular diagnostic study, specifically an ultrasonic scanning procedure with display of both two - dimensional structure and motion with NICHOLSON & EASTIN. LLP 707 N. E. THIRD AVENUE, SUITE 301, FORT LAUDERDALE, FLORIDA 33304 15 0 PageID 16 time and Doppler ultrasonic signal documentation with spectral analysis and / or color flow velocity mapping or imaging. See L28936: Non - Invasive Evaluation of Extremity Veins, First Coast Service Options, a copy of which is attached as Exhibit 6. 48. FCSO considers non - invasive evaluation of extremity veins to be medically necessary for the, " [ E ] valuation patient with symptomatic varicose veins such as stasis ulcer of the lower leg, significant pain and significant edema that interferes with activities of daily living that have not resolved following three months of conservative therapy, and symptoms are suspected to be secondary to venous insufficiency, and testing is performed to confirm this diagnosis by documenting venous valvular incompetence prior to an invasive therapeutic intervention. " Id. (emphasis added) . 49. It is expected that one complete bilateral duplex scan will precede the development of the plan of care and one unilateral (or bilateral if both extremities are treated) study post treatment may be performed if supported in the plan of care. Additional studies in the absence of new or recurrent symptoms during the 90 - day episode of care may result in a prepayment medical review. 50. Here, Dr. Siddiqui did not order any conservative therapy prior to performing the first diagnostic ultrasound. Additionally, Dr. Siddiqui ordered and billed no less than six (6) diagnostic ultrasounds from November 6, 2014, through March 12, 2015, in excess of that which is considered medically necessary under these circumstances. 51. Upon information and belief, Dr. Siddiqui routinely ordered diagnostic ultrasounds for patients for whom conservative therapy was not attempted; who did not meet the required coverage criteria; for whom diagnostic testing was not medically necessary; and for whom it was not " reasonable and necessary " as required by CMS. NICHOLSON & EASTIN. LLP 707 N. E. THIRD AVENUE. SUITE 301, FORT LAUDERDALE, FLORIDA 33304 16 0 Pageld 17 Count I Violation of the False Claims Act 31U.S. C. $ 3729 (a) (1) (A) False Claims 52. Relator realleges and incorporates by reference the allegations made in Paragraphs 1 through 51 of this Complaint. 53. This is a claim for treble damages and penalties under the False Claims Act, 31U.S. C. § 3729 et seq ., as amended. 54. Through the acts described above and otherwise, Defendants and their agents and employees knowingly (or with reckless disregard to the truth or falsity thereof) submitted or caused to be submitted false claims to Medicare for payment by the United States from at least 2014 to present. 55. The United States, Medicare, and its fiscal intermediaries, unaware of the falsity of the records, statements, and claims made or submitted by Defendants and their agents and employees, paid and continue to pay Defendants for claims that would not be paid if the truth were known. 56. By reason of the Defendants ' false records, statements, claims, and / or omissions, the United States and the Medicare program have been damaged. Thus, Defendants violated the False Claims Act, in that they knowingly presented and to caused to be presented false or fraudulent claims for payment or approval, in violation of 31U.S. C. § 3729 (a) (1) (A) . NICHOLSON & EASTIN, LLP 707 N. E. THIRD AVENUE, SUITE 301. FORT LAUDERDALE, FLORIDA 33304 17 0 Pageld 18 Count II Violation of the False Claims Act 31U.S. C. 3729 (a) (1) (B) False Statements 57. Relator realleges and incorporates by reference the allegations made in Paragraphs 1 through 51 of this Complaint. 58. This is a claim for treble damages and penalties under the False Claims Act, 31U.S. C. 3729 et seq ., as amended. 59. Through the acts described above and otherwise, Defendants and their agents and employees knowingly (or at least with reckless disregard to the truth or falsity thereof) made, used or caused to be made or used, false records or statements to get false or fraudulent claims paid or approved by the United States since at least 2014. 60. The United States, Medicare, and its fiscal intermediaries, unaware of the falsity of the records, statements, and claims made or submitted by Defendants and their agents and employees, paid and continue to pay Defendants for claims that would not be paid if the truth were known. 61. By reason of the Defendants ' false records, statements, claims, and / or omissions, the United States and the Medicare program have been damaged. Thus, Defendants violated the False Claims Act, in violation of 31U.S. C. $ 3729 (a) (1) (B) . Count III Violation of the False Claims Act 31U.S. C. 83729 (a) (1) (G) Failure to Repay Overpayment 62. Relator realleges and incorporates by reference the allegations made in Paragraphs 1 through 51 of this Amended Complaint. NICHOLSON & FASTIN. II. P 707 N. E. THIRD AVENUE, SUITE 301. FORT LAUDERDALE, FLORIDA 33304 IN 0 Pageld 19 63. This is a claim for treble damages and penalties under the False Claims Act, 31U.S. C. § 3729 et seq ., as amended. 64. Through the acts described above and otherwise, Defendants and their agents and employees knowingly and improperly failed to timely disclose and repay to Medicare payments Defendants received for services that should not have been initially paid by Medicare. Defendants had a legal obligation to disclose and refund to Medicare overpayments Defendants received within 60 days of Defendants becoming aware of the existence of the overpayment. By failing to timely voluntarily disclose and repay these identified overpayments, Defendants concealed and avoided an obligation to pay or transmit money to the government in violation of the False Claims Act. 65. By reason of the Defendants ' failure to repay Medicare overpayments, the United caso States and the Medicare program have been damaged in the amount of tens of millions of dollars. 66. Thus, Defendants violated the False Claims Act, in violation of 31U.S. C. S 3729 (a) (1) (G) . Prayer for Relief WHEREFORE, Plaintiff / Relator prays for judgment against defendants as follows: i. That Defendants cease and desist from violating 31U.S. C. § 3729 et seq .; ii. That the Court enter judgment against defendants in an amount equal to three times the amount of damages the United States has sustained as a result of Defendants ' actions, as well as a civil penalty against each defendant of $ 11, 000 for each violation of 31U.S. C. § 3729; That the Relator be awarded the maximum amount allowed pursuant to $ 3730 (d) of the Civil False Claims Act; NICHOLSON & Tastin, LLP 707 N. E. THIRD AVENUE. SUITE 301. FORT LAUDERDALE, FLORIDA 33304 19 0 Pageld 20 iv. That the Relator be awarded all costs and expenses of this action, including attorneys ' fees; and v. That the United States and the Relator receive all such other relief as the Court deems just and proper. Jury Demand Pursuant to Rule 38 of the Federal Rules of Civil Procedure, Plaintiff / Relator hereby demands trial by jury. DATED: June 13, 2016 Respectfully submitted, Valea Robert N. Nicholson, P. A. Florida Bar No. 933996 Robert @ NicholsonEastin. com Parker D. Eastin, P. A. Florida Bar No. 48044 Parker @ Nicholson Eastin. com Nicholson & Eastin, LLP 707 NE 3 Ave ., Suite 301 Fort Lauderdale, Florida 33304 Telephone: (954) 634 - 4400 Facsimile: (954) 634 - 4418 NICHOLSON & EASTIN, LLP 707 N. E. THIRD AVENUE. SUITE 301. FORT LAUDERDALE, FLORIDA 33304 20