United States v. Krizek

859 F.Supp. 5 (1994)

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Nature of the Case

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Facts

D is a psychiatrist. D and his wife Blanka Krizek were responsible for overseeing D's billing operation. D's practice consists of Medicare and Medicaid patients. D provides psychotherapy and other psychiatric care to patients at the Washington Hospital Center. Claims for reimbursement are submitted on 1500 Forms. The American Medical Association's 'Current Procedural Terminology' (CPT) manual lists the terms and codes for reporting procedures performed by physicians and to be used on 1500 Forms. Medicare required that D was to maintain documentation for each claim he submitted to Medicare. The submission of a claim on the 1500 form is a certification by the provider to the government of the correctness of the information submitted and, among other things, that the services were performed by the provider, and that the provider will maintain 'such records as are necessary to disclose fully the extent of the services provided. . . .' D was providing valuable medical and psychiatric care during the period covered by the complaint. The testimony was undisputed that D worked long hours on behalf of his patients, most of whom were elderly and poor. P filed this civil suit against Ds under the False Claims Act, 31 U.S.C. §§ 3729-3731, and at common law. P alleged false billing for Medicare and Medicaid patients. The five counts include claims for (1) 'Knowingly Presenting a False or Fraudulent Claim,' (2) 'Knowingly Presenting a False or Fraudulent Record,' (3) 'Conspiracy to Defraud the Government,'(4) 'Payment under Mistake of Fact,' and (5) 'Unjust Enrichment.' P asked for triple the alleged actual damages of $245,392 and civil penalties of $10,000 for each of the 8,002 allegedly false reimbursement claims pursuant to 31 U.S.C. § 3729. P alleges that D 'up-coded' the bills for patients by submitting bills coded for a service with a higher level of reimbursement than that provided. P also alleged that D 'performed services that should not have been performed at all in that they were not medically necessary.' P sued on 8,002 reimbursement claims. It was decided that this case should initially be tried on the basis of seven patients and two hundred claims that P believed to be representative.