COLUMBIA, S.C. (WCBD) – Doctors Care and South Carolina medical groups will pay $22.5 million to resolve civil allegations of healthcare fraud.

It comes after a whistleblower complaint alleged Doctors Care, the state’s largest urgent care provider network, and its management company, UCI Medical Affiliates of South Carolina, falsely certified that certain urgent care visits were performed by providers who were credentialed to bill Medicaid, Medicare, and TRICARE for medical services.

Instead, the lawsuit states the services were performed by non-credentialed providers.

According to Acting United States Attorney for the District of South Carolina, M. Rhett DeHart, federal health insurance companies require physicians and midlevel providers to apply for and receive approval to bill any services to the insurer.  He said this approval is known as a provider’s “billing credentials.” 

Providers are obligated to renew these billing credentials periodically and must obtain new credentials with new employment. 

According to a news release provided by DeHart’s office, the lawsuit alleges that UCI was unable to secure and maintain necessary billing credentials for most Doctors Care providers dating back to 2013.

It also states that UCI knew that federal insurance programs would deny claims submitted with the billing number of a provider who had not yet received their billing credentials. “But instead of solving its credentialing problem – or holding claims while a temporary solution could be found – UCI allegedly submitted the claims falsely, “linking” the uncredentialed rendering providers to credentialed billing providers in order to get the claims paid,” DeHart’s office reported.

With each “linked” bill, it is alleged that UCI knowingly submitted a false claim for payment.  Evidence obtained in support of the allegations includes emails memorializing UCI’s “linking” scheme and well-organized “cheat sheets,” as employees called them, which UCI used to keep track of properly-credentialed billing providers whose names could be substituted on uncredentialed providers’ bills.

The “billing credentials” at issue in this case are distinct from a provider’s degree or license to practice medicine.  There is no evidence in this case that any Doctors Care provider lacked a medical license or that patient care was compromised due to the conduct at issue.

“When healthcare companies do business with the federal government, they must follow the rules like everyone else,” said DeHart. “All companies with this distinction – regardless of size – should honor their commitment to provide competent care to the full letter of the law.  Our office will continue to protect tax dollars and ensure the rule of law is followed.”

“Taxpayers and Medicare patients rightly expect medical providers to be properly credentialed before billing for their services,” said Derrick L. Jackson, Special Agent in Charge of the Office of Inspector General for the U.S. Department of Health and Human Services (“HHS-OIG”).  “Working with our law enforcement partners, we will continue protecting Federal healthcare programs.”

The $22.5 million settlement comes after more than three years of investigations which were led by the US Attorney’s Office in coordination with the HHS-OIG and DCIS.