Lehigh Valley surgeon, Dr. Maneesh Ailawadi, has agreed to a $45,000 settlement to address allegations under the False Claims Act related to improper billing practices for Medicaid and Medicare. The claims involve billing full-price for esophagogastroduodenoscopies, known as EGDs, a portion of these procedures—specifically inspections of the duodenum—were not performed, according to the U.S. Attorney’s Office.
EGDs are medical procedures designed to look at the lining of esophagus, stomach, and the beginning of the small intestine, which are critical in identifying various conditions and determining appropriate treatments for bariatric patients. Ailawadi, who had privileges at Steward Easton Hospital, allegedly submitted claims for full EGDs using CPT Code 43239 without reduced service modifier 52, despite not fully examining an duodenum. These claims were submitted between January 1, 2019, and March 31, 2020.
"The United States Attorney’s Office for the Eastern District of Pennsylvania places a high priority on enforcement in cases involving healthcare fraud," United States Attorney Jacqueline C. Romero remarked to U.S. Attorney’s Office. She vowed to hold accountable those who submit fraudulent bills to federal healthcare programs. Special Agent in Charge for the U.S. Department of Health and Human Services Office of Inspector General, Maureen R. Dixon, also reaffirmed their dedication to investigating allegations of fraud, underscoring the partnership with the U.S. Attorney’s Office to uphold the integrity of Federal Healthcare Programs.
The settlement resolves a lawsuit that was initially filed under the whistleblower provisions of the False Claims Act by a former employee of Steward Easton Hospital. The whistleblower, whose lawsuit facilitated the uncovering of the fraudulent activity, was represented by Brian J. McCormick, Jr., of Ross Feller Casey, LLP. The United States Department of Health and Human Services Office of Inspector General, along with other members of the U.S. Attorney’s Office, notably Assistant U.S. Attorneys Deborah W. Frey and Eric D. Gill, conducted the investigation leading to this settlement.
While this settlement covers the allegations brought against Ailawadi, it is important to note that there has been no determination of liability and the claims settled are allegations only. The agreement to pay the sum of $45,000 plus interest serves as Ailawadi's acknowledgment of the case's potential impact and closes the chapter on these specific accusations affecting Medicare and Medicaid services.
