Dr. Gabriel Feldman, a board-certified preventive medicine physician, was employed by the New York County Health Services Review Organization as a local medical director. One of his primary responsibilities was to determine whether a Medicaid patient qualified for 24-hour personal care services (PCS) under Medicaid’s PCS program. Pursuant to Medicaid regulations, the local medical director is responsible for the final determination of the patient’s eligibility and amount of care to be provided in the PCS program.

According to a False Claims Act qui tam action filed by Dr. Feldman, the City of New York overruled his PCS determinations on a regulator basis, thus improperly authorizing PCS for thousands of New York Medicaid beneficiaries. Moreover, Dr. Feldman alleged that, in other instances, the City ignored his PCS determinations for additional services, thus withholding much-needed medical services from patients, potentially endangering their health and welfare.

The U.S. Government has intervened in this action, filing its complaint-in-intervention last week in the Southern District of New York. Specifically, the Government alleges that New York City’s misactions have wrongfully drained the Medicaid program of at least tens of millions of dollars.

In a variety of government health care programs, local medical directors are entrusted with the final say on whether a patient qualifies and at what level of care. Local medical directors, arguably, have the patients’ best interest in mind when making these determinations, and they are not tempted to steal public health care dollars for the benefit of their employers. However, where the local medical director’s determinations are influenced, overruled or ignored by their employers, the patients and government health care programs suffer.

For more information about qui tam law and health care fraud, contact Nolan & Auerbach, P.A.