United States of America, Appellant/cross-Appellee v. George O. Krizek, M.D., Appellees/cross-Appellants

111 F.3d 934, 324 U.S. App. D.C. 175, 1997 U.S. App. LEXIS 9859, 1997 WL 215996
CourtCourt of Appeals for the D.C. Circuit
DecidedMay 2, 1997
Docket96-5045, 96-5046
StatusPublished
Cited by107 cases

This text of 111 F.3d 934 (United States of America, Appellant/cross-Appellee v. George O. Krizek, M.D., Appellees/cross-Appellants) is published on Counsel Stack Legal Research, covering Court of Appeals for the D.C. Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
United States of America, Appellant/cross-Appellee v. George O. Krizek, M.D., Appellees/cross-Appellants, 111 F.3d 934, 324 U.S. App. D.C. 175, 1997 U.S. App. LEXIS 9859, 1997 WL 215996 (D.C. Cir. 1997).

Opinion

Opinion for the court filed by Circuit Judge SENTELLE.

SENTELLE, Circuit Judge.

This appeal arises from a civil suit brought by the government against a psychiatrist and his wife under the civil False Claims Act (“FCA”), 31 U.S.C. §§ 3729-3731, and under the common law. The District Court found defendants liable for knowingly submitting false claims and entered judgment against defendants for $168,105.39. The government appealed, and the defendants filed a cross-appeal. We hold that the District Court erred and remand for further proceedings.

I.

The government filed suit against George and Blanka Krizek for, inter alia, violations of the civil FCA, 31 U.S.C. §§ 3729-3731. Dr. George Krizek is a psychiatrist who prae- *936 ticed medicine in the District of Columbia. His wife, Blanka Krizek, worked in Dr. Kri-zek’s practice and maintained his billing records. At issue are reimbursement forms submitted by the Krizeks to Pennsylvania Blue Shield (“PBS”) in connection with Dr. Krizek’s treatment of Medicare and Medicaid patients.

The government’s complaint alleged that between January 1986 and March 1992 Dr. Krizek submitted 8,002 false or unlawful requests for reimbursement in an amount exceeding $245,392. The complaint alleged two different types of false claims: first, some of the services provided by Dr. Krizek were medically unnecessary; and second, the Kri-zeks “upcoded” the reimbursement requests, that is billed the government for more extensive treatments' than were, in fact, rendered.

A doctor providing services to a Medicare or Medicaid recipient submits a claim for reimbursement to a Medicare carrier, in this case PBS, on a form known as the “HCFA 1500.” The HCFA 1500 requires the doctor to provide his identification number, the patient’s information, and a five-digit code identifying the services for which reimbursement is sought. A list of the five-digit codes is contained in the American Medical Association’s Current Procedures Terminology Manual (“CPT”). For instance, the Manual notes that the CPT code “90844” is used to request reimbursement for an individual medical psychotherapy session lasting approximately 45 to 50 minutes. The CPT code “90843” indicates individual medical psychotherapy for 20 to 30 minutes. An HCFA 1500 lists those services provided to a single patient, and may include a number of CPT codes when the patient has been treated over several days or weeks.

Before the District Court, the government argued that the amount of time specified by the CPT for each reimbursement code indicates the amount of time spent “face-to-face” with the patient. The government focused on the Krizeks’ extensive use of the 90844 code. According to the government, this code should be used only when the doctor spends 45 to 50 minutes with the patient, not including time spent on the phone in consultation with other doctors or time spent discussing the patient with a nurse. The government argued that the Krizeks had used the 90844 code when they should have been billing for shorter, less-involved treatments.

Based on its claims of unnecessary treatment and up-coding the government sought an extraordinary $81 million in damages. This amount included $245,392 in actual damages and civil penalties of $10,000 for each of 8,002 separate CPT codes. During a three-week bench trial, the District Court determined that the case would initially be tried on the basis of seven patients which the government described as representative of the Krizeks’ improper coding and treatment practices. United States v. Krizek, No. 93-0054 (D.D.C. March 9, 1994) (Protective Order). The determination of liability would then “be equally applicable to all other claims.” Id. On July 19, 1994, the District Court issued a Memorandum Opinion, United States v. Krizek, 859 F.Supp. 5, 8 (D.D.C.1994) [hereinafter Krizek I], holding that the government had not established that the Krizeks submitted claims for unnecessary services. The Court noted that the government’s witness failed to interview the patients or any doctors or nurses. Id. The District Court also rejected the government’s theory that the Krizeks were liable for requesting reimbursement when some of the billed time was spent out of the presence of the patient. Id. at 10. The Court found that it was common and proper practice among psychiatrists to bill for time spent reviewing files, speaking with consulting physicians, ete. Id.

Despite having rejected the government’s arguments on these claims, the Court determined that the Krizeks knowingly made false claims in violation of the FCA. Id. at 13. The Court found that because of a “seriously deficient” system of recordkeeping the Kri-zeks “submitted bills for 45-50 minute psychotherapy sessions ... when Dr. Krizek could not have spent the requisite time providing services, face-to-face, or otherwise.” Id. at 11, 12. For instance, on some occasions within the seven-patient sample, Dr. Krizek submitted claims for over 21 hours of patient treatment within a 24r-hour period. Id. at 12. The Court stated, “While Dr. *937 Krizek may have been a tireless worker, it is difficult for the Court to comprehend how he could have spent more than even ten hours in a single day serving patients.” Id. The Court stated that these false statements

were not “mistakes” nor merely negligent conduct. Under the statutory definition of “knowing” conduct the Court is compelled to conclude that the defendants acted with reckless disregard as to the truth or falsity of the submissions. As such, they will be deemed to have violated the False Claims Act.

Id. at 13-14.

Having found the Krizeks liable within the seven-patient sample, the Court attempted to craft a device for applying the determination of liability to the entire universe of claims. Here, the District Court relied on the testimony of a defense witness that he could not recall submitting more than twelve 90844 codes — nine hours worth of patient treatment — for a single day. Id. at 12. Based on this testimony, the District Court stated that nine hours per day was “a fair and reasonably accurate assessment of the time Dr. Krizek actually spent providing patient services.” Id. The Court, accordingly, determined that the Krizeks would be liable under the FCA on every day in which

claims were submitted in excess of the equivalent of twelve (12) 90844 claims (nine patient-treatment hours) in a single day and where the defendants cannot establish that Dr. Krizek legitimately devoted the claimed amount of time to patient care on the day in question.

Id. at 14.

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111 F.3d 934, 324 U.S. App. D.C. 175, 1997 U.S. App. LEXIS 9859, 1997 WL 215996, Counsel Stack Legal Research, https://law.counselstack.com/opinion/united-states-of-america-appellantcross-appellee-v-george-o-krizek-cadc-1997.