United States v. Krizek

Rule of Law:

Under the False Claims Act, a defendant acts 'knowingly' if they act with reckless disregard for the truth or falsity of the information submitted; a failure to supervise billing practices or verify the accuracy of claims that results in billing for impossible hours constitutes such reckless disregard.

Facts:

• Dr. Krizek was a psychiatrist treating Medicare and Medicaid patients, while his wife and an employee were responsible for submitting reimbursement claims.
• The billing agents routinely utilized CPT code 90844, representing a 45-50 minute individual psychotherapy session, based on a standing presumption that every patient visit lasted this duration unless told otherwise.
• Mrs. Krizek and the employee did not review the medical records or communicate with the doctor to verify the actual time spent on each patient before submitting the bills.
• Dr. Krizek admitted to a practice of 'bundling' services, billing for 45-50 minute sessions that included time spent consulting with staff or reviewing files outside the patient's presence.
• On multiple occasions, the billing agents submitted claims equivalent to over 21 hours of patient services within a single 24-hour period, including one instance of billing for approximately 23 hours in one day.
• The doctor did not verify these claims prior to submission, despite certifying that the services were performed as described.

Procedural Posture:

• The United States filed a civil suit against Dr. Krizek and his wife in the U.S. District Court for the District of Columbia alleging violations of the False Claims Act and common law.
• The parties agreed to a bench trial initially regarding liability for the coding practices involving seven representative patients and two hundred specific claims.