A local optometrist is facing allegations that he submitted hundreds of fraudulent claims for Medicare and Medicaid payments over a six-year period.
Dr. Phillip Robinson and employer Associates in Eye Care P.S.C. — which has offices in seven cities in both south-central Kentucky and Tennessee, including Somerset (according to their website, www.seemuchbetter.com) — are listed as defendants in a complaint filed in U.S. District Court, Eastern District, by Kerry Harvey, a United States Attorney.
The complaint — dated May 13, 2013 — states that from January 2007 through January 2012, Robinson “provided, or claimed to provide eye examinations and other optometric services to Medicare and Kentucky Medicaid beneficiaries residing in nursing homes” in the eastern part of Kentucky. The lawsuit also states that Associates in Eye Care (AEC) submitted those claims for payment “for Robinson’s actual or alleged optometric services.”
The complaint alleges that “(i)rrespective of condition or diagnosis, Robinson provided eye examinations to most of his nursing home patients on a monthly basis, a frequency that was unreasonable and unnecessary given the patients’ medical conditions.”
Robinson is alleged to have performed an excessively high volume of exams to nursing home patients — more than 50 a day — and on at least 11 different occasions, 100 or more Medicare and Kentucky Medicaid patients in a single day, according to Harvey’s claims.
“To the extent they were actually performed, these eye examinations were so cursory that they failed to provide the level of service necessary to justify Robinson and AEC’s claims to Medicare and Kentucky Medicaid,” reads the complaint. “ ... These claims were false or fraudulent in that they requested payment for optometric services that were not medically reasonable or necessary, and/or claimed reimbursement for a level or type of optometric service that was not actually provided.”
Robinson was allegedly the optometrist at AEC that did this “with limited exception,” increasing his examinations in 2007. The complaint compares these numbers to those Robinson allegedly maintained the year before: in 2006, Robinson billed Medicare (via AEC) for 152 services moderate complexity (typically about 25 minutes long) and seven of low complexity (typically about 15 minutes, for $7,210.75 in reimbursements, part of a Medicare total for the year of over $9,574.
In 2007, continued the complain, Robinson billed Medicare for 512 of the first kind of service and 1,303 of the second kind, resulting in reimbursements of $70,624.46, for a 2007 total of more than $245,934. By 2011, alleged Harvey, those numbers exceeded $400,000.
“Robinson established a pattern of visiting each nursing home every four to six weeks, and examining all or nearly all of his patients within those homes each time he visited,” reads the complaint, which pointed to a patient of the former Britthaven nursing home in Somerset who was allegedly examined 61 times between January 2007 and December 2011, approximately once per month for five years.
“(The patient’s) primary diagnoses were typically redness of the eye or other external issues,” reads the suit, “With rare exception, the only plan of treatment indicated in AEC’s medical records for the sixty-one examinations Robinson provided to (the patient) is “monitor(ing).”
In addition to the alleged 11 dates on which Robinson purported to provide services to 100 or more nursing home patients, there are at least 271 other dates during the relevant time period on which the defendant claimed to provide services to 50 or more, according to the suit, which states that an optometrist like Robinson could typically be expected to treat only 30 such patients in an eight-hour day.
The suit claims that Robinson “knew or should have known ... that these optometric services were no medically reasonably or necessary,” and that likewise, AEC should have known the same, and that “related claims for payment misrepresented the necessity of the service.”
The suit claims that Medicare and Kentucky Medcaid paid AEC at least $987,475.78 during the relevant time period, and that defendants are liable to the United States for treble damages under the False Claims act in an amount to be determined at trial, plus a civil penalty of $5,500 to $11,000 for each false claim presented.
Jennifer L. Wintergerst, an attorney for AEC, reportedly told the Lexington Herald-Leader that the company and Robinson “vehemently dispute” the allegations, and that Robinson’s numbers are high because he is the only optometrist seeing patients in 10 different counties, many of them needing to be closely monitored because of age and health conditions.