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United States of America & The St. of Tx., Ex Rel. Bernhard Wolf, M.D. Rachel Sonnier, Et Al vs. Orange Pediatric, Felipe Sarda

Case Conclusion Date: 09.21.2007

Practice Area: Health Care

Outcome: Criminal action dismissed & Civil Resolution reach

Description: The Federal Government alleged that Dr. Sarda overbilled for Synagis injections, the upcoding of office exams to include a URI diagnosis, biling for in-hospital treatment when the patient was not in the hospital, and other billings undocumented in the medical records. A review of the sole source records for Synagis purchases compared to the milligrams billed to Medicaid revealed that the over-billing for the Synagis injections is $368,906 over a three year period. A review of medical records for URI diagnosis suggests over-billing based on an erroneous URI diagnosis to be at least $100,000 but could be higher with more refined sampling. Although, further medical records analysis reveal other undocumented upcoding and false charges we have not determined a total amount. Electronic Data Systems (EDS) the government contractor responsible for accepting billings/claims for Texas Medicaid and to conduct Medicaid fraud investigations, provided minimal information to educate physicians or their staff on how to bill for Synagis. There were no educational classes, trainers, or tutors for Orange Pediatric that EDS provided to show that they were billing incorrectly. What is Synagis? It is a vaccine used to prevent serious lower respiatory tract disease caused by Respiratory Syncytial Virus (RSV) in pediatric patients at high risks for RSV disease. The vaccine is administered at 15mg per kg of body weight, once a month during expected periods of RSV prevalance on the community. Synagis is covered by Medicaid and does not require prior authorization if: the patient is under two years of age at the first inject, with a chronic lung or respiratory condition (full term or premature); the patient was born prematurely (less than 28 weeks) and under the age of one at the first injection; or the patient was born prematurely (29 to 35 weeks) and is under the age of six mmonths at the time of first injection. Prior authorization is required for patients who do not meet the above criteria, but are at risk for RSV. RSV-IgIM must be billed per milligram and RSV-IgIV must be billed per 50 mg vial; limit 4 units per day. Providers must indicate the name of the medication and the dosage when submitting bills. RSV prophylaxis is given monthly during the RSV season. In Texas, the RSV season is considered October through April. (TDH Children with Special Health Care Needs Providers Bulletins November 2003 and February 2005). Dr. Sarda, cooperated with investigators and prosecutors. Dr. Sarda acknowledged the possibility of inadvertent provable wrong doing. Dr. Sarda has implemented a compliance program that will ensure proper billing practice. There will also be independent medical audits.

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