Eye Centers of Florida: Visual-Acuity Records Used to Qualify Cataract Claims
In the Eye Centers Florida visual acuity settlement, the practice agreed to pay $525,000 over allegations that employees falsified records to qualify patients for Medicare cataract surgery. Two whistleblowers who had worked inside the practice brought the qui tam case. Their complaint described a chart rewritten for the same examination and instructions that kept patients from trying smaller letters on a vision test. The alleged changes reached the question that determined whether the practice could bill for surgery.
The Department of Justice announced the settlement on October 23, 2018. It described Eye Centers of Florida as an ophthalmology practice with its main clinic in Fort Myers and 11 office locations throughout southwest Florida. The government’s allegations concerned certain patients covered by the Advantica plan named in its account and referred to the practice’s owner for cataract evaluations, with the alleged record falsification running from January 1, 2012, through March 1, 2014.
The Same Examination, Worse Vision on Paper
The whistleblowers alleged that a patient’s chart was rewritten to show worse vision than the examination had measured. Their complaint described an examination on November 6, 2013 that one of them had personally performed. Her original entries recorded visual acuity of 20/30 and 20/25. The rewritten chart carried the same examination date but recorded 20/50 and 20/50.
That difference mattered to payment. Visual acuity measures the sharpness or clarity of vision, generally through a person’s ability to distinguish letters or images of different sizes at a fixed distance. In its announcement, the Justice Department explained that Medicare generally considered cataract surgery reasonable and necessary when, among other conditions, the patient’s visual acuity was worse than 20/40 and impaired needed or desired activities.
The complaint tied the alleged chart changes directly to the coverage requirement:
When the examination results for cataract evaluations which were almost always administered to Medicare patients did not meet the visual acuity requirements for Advantica Medicare coverage, the charts were altered.
The alleged rewrite gave the same examination a different financial consequence. The first chart recorded what the patient could see. According to the complaint, its replacement recorded the worse vision needed to support coverage.
Keeping the Smaller Letters Out of the Test
The complaint also alleged that staff conducting vision tests received instructions limiting which letters patients could try to read. The allegation reached how the score was produced, before it reached the chart:
The Lead OA instructed the OAs, for example, that they should not even give patients the opportunity to try to read the smaller rows of letters on the refraction test or “push” them to do so.
The complaint described both the testing instruction and the later rewriting of results, giving insiders different places to recognize the alleged conduct.
The government’s settlement account followed the records into the bill. It alleged that employees knowingly made patients’ scores appear worse than the scores they had actually received, allowing Eye Centers to bill for cataract surgeries that otherwise would not have qualified under Medicare guidelines. In that account, patients were put forward for surgery their actual scores did not support, and taxpayers were billed for it.
The Payment Question Was Eligibility for Surgery
The Eye Centers allegations centered on the patient’s eligibility for a procedure. In medical device reimbursement, Medicare commonly pays for the procedure or facility service that includes an implant. The clinical record supporting that service can therefore matter to the payment for the whole procedure.
Here, the government alleged that the practice changed the evidence used to qualify patients for cataract surgery. The examination result became the support for the eligibility decision, and that decision supported the bill. The alleged manipulation sat inside the clinical workflow, where employees knew how the test had been performed and what the original chart said.
What Evidence Is Needed to Prove Fraud?
We help insiders assess how the examination result, the version used to support surgery and the resulting claim for payment fit together. The whistleblowers’ account supplied a particularly useful comparison: an original chart and a rewritten chart bearing the same examination date, with one whistleblower saying she had performed and documented the test herself.
The complaint located the original scores in the chart’s CC section and the employee’s initials under W/up Tech. Her account tied the recorded result to the person who performed and documented the examination. The date on the replacement chart still pointed to that examination, even though the vision scores had changed.
Someone who performed the examination may know what the patient actually read. Someone familiar with the chart may recognize the changed entries. Someone handling billing may see how that record supported the claim. Those different views can explain how an alleged change in a clinical record became a demand for government money.
How Much Is a Whistleblower Claim Worth?
A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. In the Eye Centers case, the Justice Department announced that the two former employees would receive a share of the settlement proceeds.
You Know What the Patient Could Read
If you saw vision scores changed or testing instructions designed to qualify patients for surgery, speak to one of our whistleblower experts about how the scores were changed. We work with you to build your strongest healthcare fraud whistleblower case and bring in healthcare fraud whistleblower lawyers who understand medical-necessity billing. We remain your partners through the pursuit of a recovery.
