CONFIDENTIAL AND UNDER SEAL – QUI TAM COMPLAINT Anonymous v. Anonymous IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF MARYLAND Baltimore Division ANONYMOUS Plaintiff, v. ANONYMOUS Defendant. ) ) ) ) ) ) ) ) ) ) ) ) ) ) Case No. ___________________ COMPLAINT FOR VIOLATIONS OF THE FALSE CLAIMS ACT, 31 U.S.C. §§ 3729, et seq. FILED UNDER SEAL JURY TRIAL DEMANDED Case 1:13-cv-01554-RDB Document 12 Filed 07/31/15 Page 1 of 19
38
Embed
IN THE UNITED STATES DISTRICT COURT FOR THE ...wboc.images.worldnow.com/library/f3941f55-295c-4236-8f76...Qui tam relator Bryan Arvey (“Relator” or “Arvey”), by his attorneys,
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
CONFIDENTIAL AND UNDER SEAL – QUI TAM COMPLAINT
Anonymous v. Anonymous
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF MARYLAND
Baltimore Division
ANONYMOUS
Plaintiff,
v.
ANONYMOUS
Defendant.
)
)
)
)
)
)
)
)
)
)
)
)
)
)
Case No. ___________________
COMPLAINT FOR VIOLATIONS OF
THE FALSE CLAIMS ACT, 31 U.S.C.
§§ 3729, et seq.
FILED UNDER SEAL
JURY TRIAL DEMANDED
Case 1:13-cv-01554-RDB Document 12 Filed 07/31/15 Page 1 of 19
CONFIDENTIAL AND UNDER SEAL – QUI TAM COMPLAINT
United States ex rel. Arvey v. Hart to Heart Transportation Services, Inc. et. al.
2
IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF MARYLAND
Baltimore Division
UNITED STATES OF AMERICA, ex rel.
BRYAN ARVEY
31895 Old Ocean City Road
Salisbury, Wicomico County, MD 21801
Plaintiff,
v.
HART TO HEART TRANSPORTATION
SERVICES, INC.
355 Granary Road, Suite A
Forest Hill, Harford County, MD 21050
EMS BILLING SOLUTIONS, INC.
355 Granary Road
Forest Hill, Harford County, MD 21050
PENINSULA REGIONAL MEDICAL
CENTER
(Susan McDonald – Registered Agent)
100 East Carroll Street
Salisbury, MD 21801
JOHN SKIDMORE
209 Holy Cross Road
Street, Harford County, MD 21154
TERRY SKIDMORE
209 Holy Cross Road
Street, Harford County, MD 21154
RICHARD SKIDMORE
45 Gomer Court
Elkton, Cecil County, MD 21921
Defendants.
)
)
)
)
)
)
)
)
)
)
)
)
)
)
)
)
)
)
)
)
)
)
)
)
)
)
)
)
)
)
)
)
)
)
)
)
)
Case No. RDB-13-1554
FIRST AMENDED COMPLAINT FOR
VIOLATIONS OF THE FALSE CLAIMS
ACT, 31 U.S.C. §§ 3729, et seq.
FILED UNDER SEAL
JURY TRIAL DEMANDED
Case 1:13-cv-01554-RDB Document 12 Filed 07/31/15 Page 2 of 19
CONFIDENTIAL AND UNDER SEAL – QUI TAM COMPLAINT
United States ex rel. Arvey v. Hart to Heart Transportation Services, Inc. et. al.
3
INTRODUCTION
1. Qui tam relator Bryan Arvey (“Relator” or “Arvey”), by his attorneys, individually and
on behalf of the United States of America, files this complaint against Hart to Heart
Transportation Services, Inc. (“HHTS”), EMS Billing Solutions, Inc. (“EMS”),
Peninsula Regional Medical Center (PMRC), John Skidmore, Terry Skidmore, and
Richard Skidmore (collectively “Defendants”) to recover damages, penalties, and
attorneys’ fees for violations of the federal False Claims Act, 31 U.S.C. §§ 3729 et seq.,
(“FCA” or “False Claims Act”).
2. John and Terry Skidmore are the owners and operators of both HHTS and EMS and are
the individuals responsible for overseeing each company.
3. Defendant HHTS is a Maryland corporation in the business of providing commercial
ambulance and other healthcare-related transportation operations services.
4. Defendant EMS is a Maryland corporation in the business of providing claims processing
and billing services. HHTS is believed to be EMS’s only client.
5. Defendant PRMC is a Maryland non-profit hospital, providing a full range of medical
services.
6. Relator Arvey is a former ambulance driver for HHTS.
7. Medicare Part B covers eighty percent (80%) of a beneficiary’s approved ambulance cost
if transportation by ambulance is a “medical necessity.” Medical necessity is established
when “the patient’s condition is such that the use of any other method of transportation is
contraindicated.”
Case 1:13-cv-01554-RDB Document 12 Filed 07/31/15 Page 3 of 19
CONFIDENTIAL AND UNDER SEAL – QUI TAM COMPLAINT
United States ex rel. Arvey v. Hart to Heart Transportation Services, Inc. et. al.
4
8. Defendant HHTS required Relator Arvey and other ambulance drivers or emergency
medical technicians (EMTs) to falsify their narratives and use inaccurate billing codes to
reflect that ambulance transport was a necessity when such transportation was, in fact,
not a necessity.
9. PRMC staff acquiesced in and facilitated the false narratives by placing patients who
were not bed ridden in their beds on the instruction of HHTS, so that EMT’s could justify
transporting them by stretcher and ambulance.
10. Requiring EMTs to falsify their narratives allows HHTS to submit claims to EMS, which
in turn, remits the claims to Medicare for payment that would otherwise need to be
collected from the individual patient.
11. In reviewing claims submitted by HHTS, EMS determines which claims are likely to be
accepted by Medicare and which will be rejected. EMS returns to HHTS those claims
that are likely to be rejected by Medicare and identifies the “corrections” necessary to
ensure acceptance by Medicare.
12. Defendant John Skidmore established and operated HHTS and EMS with the intent to
defraud the United States through the submission of false Medicare claims.
13. Defendant Richard Skidmore is employed as the Vice President of Operations and Safety
to HHTS and explicitly instructed Relator and other HHTS employees to create false
records in support of fraudulent the company’s fraudulent Medicare claims.
14. In violation of 31 U.S.C. §§ 3729(a)(1)(A), Defendants submitted or caused to be
submitted false Medicare claims when they billed Medicare for ambulance transportation
that they knew was not medically necessary.
Case 1:13-cv-01554-RDB Document 12 Filed 07/31/15 Page 4 of 19
CONFIDENTIAL AND UNDER SEAL – QUI TAM COMPLAINT
United States ex rel. Arvey v. Hart to Heart Transportation Services, Inc. et. al.
5
15. In violation of 31 U.S.C. §§ 3729(a)(1)(B), Defendants knowingly caused the creation of
false records in support of those false claims to meet the documentation requirements
imposed upon them by the Medicare program.
16. In violation of 31 U.S.C. §§ 3729(a)(1)(C), Defendants entered into a conspiracy to
defraud the United States by submitting false or fraudulent Medicare claims and by
creating false records in support of those false or fraudulent Medicare claims.
17. Relator estimates that approximately half of the 50,000 ambulance pick-ups he observed
during his time employed by defendants were not medically necessary.
18. Focusing only on the pick-ups by Relator, himself, could result in the submission of false
Medicare claims in the millions of dollars.
19. Relator and other current and former ambulance drivers and EMTs confirm that the
practice of submitting false reports is “very common” and “happens all the time.” Thus,
it is reasonable to assume that drivers other than Relator are forced to submit false
reports.
20. HHTS has been in business for nearly seventeen (19) years and, at present, provides
approximately 69,000 transports per year relying on eighty road units. Depending upon
the prevalence and duration of the falsely submitted claims, the damages to the United
States could be in the tens of millions of dollars.
21. To Relator’s knowledge, Defendants’ fraud remains ongoing through to the present.
JURISDICTION AND VENUE
22. This Court has subject matter jurisdiction over this action under 28 U.S.C. § 1331 and 31
U.S.C. § 3732(a).
Case 1:13-cv-01554-RDB Document 12 Filed 07/31/15 Page 5 of 19
CONFIDENTIAL AND UNDER SEAL – QUI TAM COMPLAINT
United States ex rel. Arvey v. Hart to Heart Transportation Services, Inc. et. al.
6
23. This Court has personal jurisdiction over Defendants pursuant to 31 U.S.C. § 3732(a)
because the Defendants transact business in this judicial district.
24. Venue is proper in this Court under 28 U.S.C. §1391(c) and 1395(a), and 31 U.S.C. §
3732(a) because the complained of illegal acts occurred within this judicial district, the
Defendant is a resident of this district, and because the Defendant transacts business
within this judicial district.
PARTIES
25. Relator Arvey is a thirty (30) year old male and resident of Wicomico County, Maryland.
26. Defendant HHTS is a Maryland Corporation, headquartered in Harford County. HHTS is
in the business of providing commercial ambulance and other healthcare-related
transportation operation services.
27. HHTS is a licensed provider for Medicare Part B services.
28. Defendant EMS is a Maryland Corporation, headquartered at the same physical address
as Defendant HHTS. EMS is in the business of claims processing for medical
transportation companies.
29. Defendant PRMC is a hospital with a full range of medical services, including 292 acute
care beds.
30. Relator made the vast majority of his pick-ups from PRMC.
31. Defendant John Skidmore is the owner, operator, and founder of both HHTS and EMS.
32. Defendant Richard Skidmore is the the Vice President of Operations and Safety at HHTS
and was Relator’s supervisor.
33. HHTS hired Arvey as a driver in the summer of 2010.
Case 1:13-cv-01554-RDB Document 12 Filed 07/31/15 Page 6 of 19
CONFIDENTIAL AND UNDER SEAL – QUI TAM COMPLAINT
United States ex rel. Arvey v. Hart to Heart Transportation Services, Inc. et. al.
7
34. At all times material to this complaint, Arvey was employed by Defendant HHTS
operating out of the company’s Salisbury, Maryland location.
35. Arvey has firsthand knowledge of Defendants HHTS’s, EMS’s, and Richard Skidmore’s
fraudulent business practices.
36. Defendant HHTS terminated Arvey’s employment in February 2013.
FACTUAL ALLEGATIONS
Founding Hart To Heart Transportation Services and EMS Billing Solutions
37. Defendant John Skidmore founded HHTS in 1996 to provide ambulance and other
healthcare-related transportation services to patients.
38. HHTS employs more than 350 people and has eighty (80) vehicles in its transportation
fleet.
39. HHTS is licensed to provide emergency medical services, wheelchair services, and sedan
services in Maryland, Delaware, Pennsylvania, and New Jersey.
40. HHTS runs approximately 69,000 transports annually and ran 62,000 transports in 2012.
Defendant’s Salisbury, Maryland location, out of which Relator worked, runs
approximately 19,500 transports annually.
41. HHTS is a licensed provider for Medicare Part B and submits a high volume of Medicare
claims for payment.
42. Approximately six years after he founded HHTS, John Skidmore founded Defendant
EMS. John Skidmore remains the owner of each company.
43. EMS is responsible for processing claims submitted by HHTS and remitting those claims
to the United States for payment through the Medicare program.
Case 1:13-cv-01554-RDB Document 12 Filed 07/31/15 Page 7 of 19
CONFIDENTIAL AND UNDER SEAL – QUI TAM COMPLAINT
United States ex rel. Arvey v. Hart to Heart Transportation Services, Inc. et. al.
8
Relator’s Job Duties And Case Reports
44. HHTS hired Relator during the summer of 2010.
45. Relator’s duties consisted of driving various healthcare-related transport vehicles –
including wheelchair transports, the cancer bus, and the critical care unit – and assisting
paramedics with the administration of emergency medical care.
46. For each completed transport, the assigned EMT is responsible for completing a case
report.
47. Completing a case report requires the EMT to identify the appropriate billing code and to
draft a narrative describing the transportation.
HHTS’s Billing Practices
48. Once an EMT completes a case report, that report is submitted to the corporate office.
49. Medical Director Scott Steinmetz, M.D., reviews the case reports and forwards them to
defendant EMS.
50. EMS analyzes the case report and, for cases to be billed to the Centers for Medicare and
Medicaid Services (CMS), ensures that the case report meets all of the requirements for
reimbursement.
51. If the case report meets all necessary requirements, EMS submits the claim to CMS for
payment.
HHTS Directs Relator And Other Employees To Falsify Case Report Narratives
52. If the case report does not meet all of the necessary requirements, EMS returns the case
report to HHTS.
Case 1:13-cv-01554-RDB Document 12 Filed 07/31/15 Page 8 of 19
CONFIDENTIAL AND UNDER SEAL – QUI TAM COMPLAINT
United States ex rel. Arvey v. Hart to Heart Transportation Services, Inc. et. al.
9
53. Included within its communications to HHTS, EMS identifies the deficiencies that would
prevent the claim from being paid by Medicare under CMS regulations.
54. Defendant Richard Skidmore or, on occasion, Lisa Sievers, Risk & Safety Director, sends
the returned case report to the driver with instructions to make the necessary
“corrections” that will, per CMS regulations, make the claim payable by Medicare.
55. Once the case reports were “corrected,” HHTS re-sent the claims to EMS which would
then remit the revised claims for payment through Medicare.
56. As a result of HHTS forcing its personnel to falsify their reports, the company requires
that its drivers and Emergency Medical Technicians (EMTs) use stretchers to transport
patients, even if stretchers were not required.
57. For a typical transport, EMTs would arrive at PRMC or other hospitals and instruct the
hospital staff to place the patient in a stretcher, even if the patient did not need one.
58. The EMT would then have the hospital staff transport the patient, who was now on the
stretcher, to the ambulance vehicle.
59. On one or more occasions, Relator called the HHTS dispatcher to report that a patient
was ambulatory and did not need a stretcher. Dispatch responded by instructing Relator
to “take the patient by stretcher anyway,” or words to that effect.
60. HHTS instructed EMTs that if they saw patients walking, they should leave the room and
ask the hospital staff to put the patient into his or her bed.
61. Once the hospital staff put the patient back in bed, the EMTs and hospital staff would
load the patient onto a stretcher and take them to the ambulance.
Case 1:13-cv-01554-RDB Document 12 Filed 07/31/15 Page 9 of 19
CONFIDENTIAL AND UNDER SEAL – QUI TAM COMPLAINT
United States ex rel. Arvey v. Hart to Heart Transportation Services, Inc. et. al.
10
62. By forcing its employees to use a stretcher during transportation, HHTS could more
easily falsify its documentation to make it appear as though transportation by ambulance
was a medical necessity.
63. If a patient absolutely refused to use the stretcher, Richard Skidmore instructed Relator
and other drivers to falsify their narratives with statements such as “[T]he patient could
not stand, walk or pivot,” or that “[T]he patient could only ambulate with ‘maximum
assistance’ where two HHTS employees were needed to move the patient around.”
64. Such statements made it seem as though transportation by ambulance was a medical
necessity, thereby increasing the chances that the claim would be paid through Medicare.
65. Relator questioned more senior EMTs and paramedics about the practice of falsifying
narratives, but his colleagues told him that he should follow Richard Skidmore’s
instructions to write false narratives.
66. Richard Skidmore threatened Relator and other employees, stating that a failure to
“correct” their case reports in this manner would result in suspension or termination.
67. Richard Skidmore’s threats were made orally and through e-mail.
68. During a period in or around September 2012 when Relator assisted with office duties,
Relator learned that Richard Skidmore instructed managers to “correct” case reports
themselves by entering an employee’s social security number to access the report within
the system.
HHTS Directs Relator And Other Employees To Falsify Billing Codes
Case 1:13-cv-01554-RDB Document 12 Filed 07/31/15 Page 10 of 19
CONFIDENTIAL AND UNDER SEAL – QUI TAM COMPLAINT
United States ex rel. Arvey v. Hart to Heart Transportation Services, Inc. et. al.
11
69. When HHTS hired Relator in the summer of 2010, the company allowed its drivers to
select from approximately fifty (50) billing codes, some of which indicated that transport
by ambulance was not a medical necessity.
70. Within a few weeks of Relator starting at HHTS, the company eliminated all but two (2)
billing codes.
71. The remaining two billing codes supported claims to Medicare because they indicated
that transportation by ambulance was a medical necessity.
72. Thus, HHTS required Relator and other employees to choose only from billing codes that
defined a particular trip as a medical necessity, even if the trip did not, in fact, meet the
requirements of medical necessity.
COUNT I
Defendants Knowingly Presented or Caused to be Presented False or Fraudulent Claims
for Payment to the United States in Violation of the False Claims Act
31 U.S.C. § 3729(a)(1)(A)
73. Arvey realleges and incorporates the allegations set forth above as though fully alleged
therein.
74. By virtue of the acts described above, Defendants knowingly presented or caused to be
presented to the United States Government false or fraudulent claims for payment or
approval under the federally-funded Medicare programs in violation of 31 U.S.C. §
3729(a)(1).
75. Medicare Part B covers eighty percent (80%) of a beneficiary’s approved ambulance
cost after the yearly deductible is paid.
Case 1:13-cv-01554-RDB Document 12 Filed 07/31/15 Page 11 of 19
CONFIDENTIAL AND UNDER SEAL – QUI TAM COMPLAINT
United States ex rel. Arvey v. Hart to Heart Transportation Services, Inc. et. al.
12
76. To be covered, ambulance transportation must be reasonable and medically necessary.
Medical necessity exists in cases where no means of transportation other than an
ambulance can be used without endangering the patient’s health.
77. Defendant HHTS provided transportation via ambulances that was not medically
necessary for thousands of patients.
78. Defendant HHTS caused false claims to be presented to the United States when it
provided these claims to EMS for processing and remittance to CMS.
79. When Defendant EMS received a Medicare claim and that did not meet CMS regulations,
it identified the deficiencies in the claim and sent the case report back to HHTS for
“correcting.”
80. HHTS, per instructions from EMS, “corrected” the claims and re-sent the case report and
false claims to EMS for processing and remittance to the government.
81. EMS, having already seen the original claims, knew or reasonably should have known
that the “corrected” claims were false when it presented them to CMS for payment.
82. Defendant PRMC acquiesced in and facilitated the medically unnecessary transport of
patients by stretcher and ambulance.
83. John Skidmore, as founder, owner, and operator of both HHTS and EMS, had knowledge
of and directed the false claim submissions and established the companies with the
purpose of engaging in fraudulent conduct.
84. Terry Skidmore, as owner and operator of HHTS, had knowledge of and directed the
false claim submissions and established the companies with the purpose of engaging in
fraudulent conduct.
Case 1:13-cv-01554-RDB Document 12 Filed 07/31/15 Page 12 of 19
CONFIDENTIAL AND UNDER SEAL – QUI TAM COMPLAINT
United States ex rel. Arvey v. Hart to Heart Transportation Services, Inc. et. al.
13
85. By reasons of the acts and conduct of the HHTS and EMS in violation of 31 U.S.C. §
3729(a)(1)(A), the United States has suffered actual damages, including the total amounts
paid in response to all such false or fraudulent claims for payment. In addition, the
United States is entitled to recover civil money penalties, and other monetary relief as
deemed appropriate.
COUNT II
Defendants Knowingly Made and Used or Caused to Be Made And Used A False Record
Material To A Fraudulent Claim in Violation of the False Claims Act
31 U.S.C. § 3729(a)(1)(B)
86. Arvey realleges and incorporates the allegations set forth above as though fully alleged
therein.
87. By virtue of the acts described above, Defendants knowingly caused the creation of false
documents and records in support of their false or fraudulent claims for payment or
approval under the federally-funded Medicare programs in violation of 31 U.S.C. §
3729(a)(1)(B).
88. Defendant HHTS created false records in at least three ways:
a. HHTS forced its employees to use billing codes that indicate ambulance service
was a medical necessity when such service, in fact, was not a medical necessity.
b. HHTS forced its employees and PRMC employees to use stretchers when
transporting patients, even when the use of such equipment was not necessary.
HHTS then created false records when it relied on the use of a stretcher as
evidence of ambulance transportation being a medical necessity.
c. HHTS falsely represented that many of its patients were non-ambulatory and
required maximum assistance to board the ambulance prior to transport. Relying
Case 1:13-cv-01554-RDB Document 12 Filed 07/31/15 Page 13 of 19
CONFIDENTIAL AND UNDER SEAL – QUI TAM COMPLAINT
United States ex rel. Arvey v. Hart to Heart Transportation Services, Inc. et. al.
14
on these false representations enabled HHTS to create fraudulent case reports to
accompany its false claims for payment to CMS.
89. Defendant EMS caused false records to be created by advising HHTS how to “correct”
claims that would not pass the criteria set forth by CMS for payment.
90. John Skidmore, as founder, owner, and operator of both HHTS and EMS, had knowledge
of and directed the creation of false records and established the companies with the
purpose of engaging in fraudulent conduct.
91. Richard Skidmore, as Vice President of Operations and Safety, directed Relator and other
HHTS employees to create false records in support of the company’s fraudulent Medicare
claims under threat of suspension or termination.
92. By reasons of the acts and conduct of the HHTS and EMS in violation of 31 U.S.C. §
3729(a)(1)(B), the United States has suffered actual damages, including the total amounts
paid in response to all such false or fraudulent claims for payment. In addition, the
United States is entitled to recover civil money penalties, and other monetary relief as
deemed appropriate.
COUNT III
Defendants Conspired To Present False or Fraudulent Claims For Payment to the
United States in Violation of the False Claims Act
31 U.S.C. § 3729(a)(1)(C)
93. Arvey realleges and incorporates the allegations set forth above as though fully alleged
therein.
94. The Federal False Claims Act, 31 U.S.C. § 3729(a)(1)(C) provides for liability against
person who conspires to commit a violation of subparagraph (A), (B), (D), (E), (F), or
(G).”
Case 1:13-cv-01554-RDB Document 12 Filed 07/31/15 Page 14 of 19
CONFIDENTIAL AND UNDER SEAL – QUI TAM COMPLAINT
United States ex rel. Arvey v. Hart to Heart Transportation Services, Inc. et. al.
15
95. In violation of 31 U.S.C. § 3729(a)(1)(C), by the foregoing acts and omissions,
Defendants conspired to violate 31 U.S.C. § 3729(a)(1)(A) and 3729(a)(1)(B).
96. John Skidmore is the common owner and founder of both Defendant HHTS and
Defendant EMS.
97. By virtue of the acts described above, Defendants HHTS, PRMC, and EMS entered into a
conspiracy to defraud the United States by presenting or causing to be presented false or
fraudulent Medicare claims for payment and by making or causing to be made false
records material to their fraudulent claims.
98. Defendant HHTS provided ambulance and other healthcare-related transportation
services that it knew was non-compliant with CMS regulations for Medicare
reimbursement. PRMC acquiesced in and facilitated medically unnecessary transport of
its patients by stretcher and ambulance. EMS advised HHTS on how to describe its
services in such a way that would increase the likelihood of payment by the United States
for HHTS’s non-compliant services.
99. By the foregoing acts and omissions, Defendants took action in furtherance of their
conspiracy when HHTS resubmitted “corrected” claims and case reports to EMS, which,
in turn, remitted the claims for payment to CMS.
100. Defendants’ were aware of the falsity of the claims and invoices submitted to the
government.
101. Defendants John, Terry, and Richard Skidmore directed HHTS and CMS to
submit false claims and create fraudulent records to support those false claims.
Case 1:13-cv-01554-RDB Document 12 Filed 07/31/15 Page 15 of 19
Case 1:13-cv-01554-RDB Document 12 Filed 07/31/15 Page 16 of 19
CONFIDENTIAL AND UNDER SEAL – QUI TAM COMPLAINT
United States ex rel. Arvey v. Hart to Heart Transportation Services, Inc. et. al.