Robert P. Oristaglio, Jr. ex rel. United States of America v. Community Care Health Network LLC, doing business as Matrix Medical Network (Matrix), DPN USA, doing business as HealthFair (HealthFair), and Shahriah “James” Ekbatani

Beaumont, Texas, civil litigation lawyers represented the Plaintiff on a qui tam action claiming that the Defendants violated the False Claims Act (FCA) by causing the submission of false or invalid diagnosis codes to the Medicare Advantage program.

Reported by Kent Morlan

The United` States alleged that during the period from 2014 to 2019, Matrix knowingly caused MAOs to submit false and invalid diagnoses of the following chronic medical conditions to CMS for risk adjustment purposes: proliferative diabetic retinopathy, drug-induced polyneuropathy, rheumatoid polyneuropathy, atrial fibrillation, rheumatoid arthritis, chronic obstructive pulmonary disease, and simple chronic bronchitis (the “Invalid Diagnoses”). Matrix reported the Invalid Diagnoses to MAOs based on its in-home assessments even though: (a) there was not sufficient information to support the diagnoses; (b) the diagnoses did not conform with the guidelines for coding and reporting diagnoses as required by CMS; and (c) the conditions were frequently not diagnosed by any other healthcare provider who saw the beneficiary during the year in which the home visit occurred or in the preceding two years or subsequent two years. As a result of the reporting of these Invalid Diagnoses, the MAOs obtained inflated risk adjustment payments from CMS to which they were not entitled.

As to HealthFair and Ekbatani, the United States contends that HealthFair knowingly reported certain diagnoses to MAOs that were unsupported, unsubstantiated, and/or invalid. Specifically, from 2015 to 2017, HealthFair providers (1) made certain diagnoses (including but not limited to HIV/AIDS, metastatic cancer, and Myasthenia Gravis) without documentation establishing or confirming the existence of the condition; (2) made certain diagnoses (including but not limited to morbid obesity, rheumatoid arthritis, coagulation defect, drug dependence, major depressive disorder, and chronic obstructive pulmonary disease) solely based on patient attestation, claims history, past medical history, or medication; (3) diagnosed congestive heart failure and heart arrhythmia despite contradiction by electrocardiogram and echocardiogram results; and (4) diagnosed thrombophilia solely based on separate diagnoses of atrial fibrillation. HealthFair, which acted at the direction of Ekbatani, submitted the diagnoses to its MAO customers, and the MAOs often submitted the diagnoses to CMS for risk-adjusted payments.

The settlement with Matrix resolves claims brought under the qui tam or whistleblower provisions of the FCA by Nancy Cahill, a former employee of Matrix, in United States ex rel. Cahill v. Matrix, No. 19-CV-11153 (S.D.N.Y.). The settlements with HealthFair and Ekbatani resolve claims brought under the qui tam or whistleblower provisions of the FCA by Robert Oristaglio, Jr., D.O., who was the chief medical officer of HealthFair, in United States ex rel. Oristaglio v. Community Care Health Network, Inc., d/b/a Matrix Medical Network et al., No. 4:22-CV-00133-SDJ (E.D. Tex.). Under the FCA, private parties are permitted to sue on behalf of the government for false claims for government funds and to receive a share of the recovery. The settlements in these cases provide for Cahill to receive $7.3 million and Oristaglio to receive $3.6 million.

This year the Administration launched the Task Force to Eliminate Fraud and the National Fraud Enforcement Division to enhance the Administration’s war on fraud, waste, and abuse in federal programs. When unscrupulous actors exploit these programs for their own financial gain, they defraud the government, harm the people these programs are designed to aid and protect, and undermine American businesses that play by the rules. The Civil Division’s FCA enforcement plays a critical role in combatting such fraudulent schemes, recovering billions of dollars for the American taxpayers, and holding wrongdoers accountable. FCA matters will continue to be on the forefront of the battle against fraud, and the Civil Division’s FCA work will support and advance the mission of the Task Force to Eliminate Fraud and the National Fraud Enforcement Division.

The resolutions obtained in this matter were the result of coordinated efforts between the Justice Department’s Civil Division, Commercial Litigation Branch, Fraud Section, and the U.S. Attorney’s Offices for the Eastern District of Texas and Southern District of New York, with assistance from HHS-OIG.

The Defendants agreed to pay $56.5 million to settle the claims made against them.

The claims resolved by the settlement are allegations only and there has been no determination of liability.