SIOUX CITY, Iowa (KCAU) – A business based in Sioux City is expected to pay hundreds of thousands of dollars to resolve allegations of false claims involving plastic surgery.

A release from the United States Department of Justice indicated that Tri-State Specialists, L.L.P., has agreed to pay $612,501.44 to the country, Iowa, and South Dakota on allegations that they violated the False Claims Act (FCA) by billing several medical insurance programs under false claims.

The false claims were about procedures that weren’t medically necessary and for reporting more procedures than they actually performed.

“False Claims Act investigations and enforcement are critical in protecting the government healthcare programs upon which millions of Americans depend. We will continue to vigorously investigate allegations of over-billing and medically unnecessary services in this district,” said United States Attorney Sean Berry. 

The programs they billed for these procedures included Medicare, Medicaid, TRICARE, and the Federal Employees Health Benefits Program.

Allegations said from August 2014 to August 2019, Tri-State sent in false claims to those healthcare providers for surgeries and visits made by a plastic surgeon that partnered with Tri-State previously.

The claims made during this time reportedly violated the FCA in the following ways.

  1. The government said the surgeon performed cosmetic procedures not reimbursable by government healthcare programs (Example: Panniculectomies, abdominoplasties, and cosmetic breast reductions).
  2. The government alleged the surgeion didn’t suffiently perform to bill for “high-value muscle flap and adjacent tissue transfer surgical procedures.”
  3. The government also alleged the surgeon didn’t perform suffiently to bill for “high-value office visits that require a comprehensive exam, comprehensive history, and detailed supporting documentation for patients that require moderately or highly complex medical decision making.”     

“We work tirelessly alongside our law enforcement partners to investigate allegations of false billing and to ensure the appropriate use of U.S. taxpayer dollars,” said Special Agent in Charge with the U.S. Department of Health and Human Services Office of Inspector General Curt Muller, “Excessive claims to Federal healthcare programs compromise the efficiency of these programs and deprive these programs of critical resources.” 

The release also explained the U.S. said Tri-State was liable for the surgeon’s acts because the surgeon was an agent of Tri-State, and they knew what the surgeon was doing.         

“As the investigative arm of the Department of Defense’s Office of Inspector General (DoD IG), one of the primary missions of the Defense Criminal Investigative Service (DCIS) is to safeguard valuable taxpayer dollars that fund programs such as Tricare, the military’s health care system,” said Acting Special Agent in Charge Gregory Shilling, “Today’s settlement is a testament to the resolve of our agents and our partners in investigating allegations of false claims and protecting taxpayer dollars.” 

The release explained the claims against Tri-State are only allegations.

The case was handled by Assistant United States Attorneys Melissa Carrington and Matthew Gillespie and the State of Iowa Attorney General’s Office and investigated by the United States Department of Health and Human Services, Office of Inspector General; the United States Department of Defense Office of Inspector General, Defense Criminal Investigative Service; the United States Office of Personnel Management, Office of the Inspector General; and the State of Iowa’s Medicaid Fraud Control Unit.