Lehigh Valley-Area Doctor Agrees to Pay $45,000 to Resolve False Claims Act Liability

PHILADELPHIA - United States Attorney Jacqueline C. Romero announced that Maneesh Ailawadi, MD, has agreed to pay $45,000 plus interest to resolve False Claims Act allegations that he caused the submission of false claims by submitting inappropriate claims to Medicaid and Medicare by improperly billing esophagogastroduodenoscopies ("EGDs") on bariatric patients at the former Steward Easton Hospital in Easton, Pennsylvania.

EGDs are procedures that examine the lining of the esophagus, stomach, and the first part of the small intestine - the duodenum. These are performed to identify symptoms that may be new, cannot be explained, or are not responding to treatment. The findings from an EGD can help surgeons decide on the most appropriate bariatric procedure and follow up care.

Ailawadi, a bariatric and general surgeon, had privileges to perform bariatric surgeries and EGDs at Steward Easton Hospital. The government alleges that Ailawadi caused the submission of false claims for payment to both Medicaid and Medicare from January 1, 2019, to March 31, 2020, arising from Ailawadi improperly billing EGD procedures using CPT Code 43239 without reduced service modifier 52 when the duodenum was deliberately not examined. According to the United States, these EGD procedures were only partially completed to save time, although Ailawadi billed the federal healthcare programs as if they had been fully completed. By failing to enter the duodenum during the EGD procedure, Ailawadi allegedly was not able to identify any abnormalities, such as bleeding, growths, ulcers, or inflammation.

"The United States Attorney's Office for the Eastern District of Pennsylvania places a high priority on enforcement in cases involving healthcare fraud," said Romero. "We will hold accountable those who bill the Federal Healthcare Programs for procedures that are either not performed, or partially performed, as was the case here."

"Today's settlement shows our attention to and commitment to investigating allegations of fraud targeting Medicare and Medicaid, whether we need to examine the potential conduct of an individual physician or several parties in a complex scheme," said Maureen R. Dixon, Special Agent in Charge for the U.S. Department of Health and Human Services Office of Inspector General. "We will continue to partner with the United States Attorney's Office to evaluate allegations brought under the False Claims Act to ensure the integrity of Federal Healthcare Programs."

This settlement resolved a lawsuit filed under the False Claims Act in the U.S. District Court for the Eastern District of Pennsylvania by a former Steward Easton Hospital employee. Under the qui tam or whistleblower provisions of the False Claims Act, lawsuits like this one may be brought on behalf of the United States and the relator shares in any recovery by the government. The relator was represented in this case by Brian J. McCormick, Jr., of Ross Feller Casey, LLP.

This matter was investigated by the U.S. Attorney's Office for the Eastern District of Pennsylvania, in conjunction with the U.S. Department of Health and Human Services Office of Inspector General. The investigation and settlement were handled by Assistant U.S. Attorneys Deborah W. Frey and Eric D. Gill, Auditor George Niedzwicki, Fraud Examiner Frank O'Connor, and Paralegal Brendan Novak.

The claims resolved by this settlement are allegations only and there has been no determination of liability.