Upcoding
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August 5, 2022
Gonzaga Interventional Pain Management, Melvin Gonzaga, M.D., and his son Rommel Gonzaga will pay $980,000 for violating the False Claims Act by submitting claims for medically unnecessary urine drug tests. GIPM required patients to submit a UDT sample before being seen by a provider and discussing the results from any prior UDT the patient received. Regardless of the patients’ individualized testing needs, GIPM always opted for the more complex “definitive” UDT rather than the lower-level “presumptive” UDT, netting a higher reimbursement rate from the US government. USAO MDAugust 4, 2022
Eastern Iowa Dermatology, PLC and Dr. Manish Kumar will pay $1.66 million for violating the False Claims Act. Defendants submitted up-coded claims to Medicare for office visits and destruction or removal of skin tags and lesions, the sole purpose of which is to increase Medicare’s reimbursement rate. In addition to the monetary penalty, they agreed to an Integrity Agreement and are subject to ongoing monitoring by the US DHHS. USAO SDIAAugust 3, 2022
North Country Neurology, P.C. will pay $850,000 for violating the False Claims Act by submitting claims falsely listing a physician as the service provider, when the services were provided instead by an unsupervised non-physician practitioner. Medicare will reimburse for certain services provided by NPPs, but require a physician to be physically present in the office and immediately available to furnish assistance. This was not the case on over 120 occasions, and NCN admitted it should have known it was improper to bill at the higher physician rather than NPP level. Additionally, NCN improperly billed Medicare on approximately 761 occasions for Botox, even though it had already been paid for by another insurer. NCN blamed their insufficient compliance program for the errors. USAO NDNYJuly 29, 2022
Old Man’s Home of Philadelphia d/b/a Saunders House, a skilled nursing facility, will pay $819,640 for its violations of the False Claims Act. A whistleblower filed suit under the qui tam provisions of the FCA, alleging Saunders House overbilled federal healthcare programs for therapy services provided; billed for therapy services not provided; billed for unreasonable, unnecessary, and sometimes harmful therapy; and manipulated clinical services to maximize billing. Medicare Part A paid Saunders House based on beneficiaries’ assigned Resource Utilization Group, and Saunders billed at the highest RUG level—Ultra High or RU—despite the lack of reasonableness or necessity for the patients. USAO EDPAApril 28, 2022
Donald Woo Lee, a California-based doctor who recruited Medicare beneficiaries to his clinics, falsely diagnosed them and provided them with medically unnecessary procedures, and then submitted upcoded bills for those procedures to Medicare, has been sentenced to nearly 8 years in prison after being found guilty of seven counts of healthcare fraud. In addition to submitting approximately $12 million in false claims to Medicare, for which he received $4.5 million in reimbursement, Lee also repackaged and reused single-use catheters on his patients. DOJApril 27, 2022
Dr. Josef Schenker and his urgent care facilities, Josef Schenker, M.D., P.C., and Care Partners Medical Management, LLC will pay $564,217.70 for violations of the False Claims Act, by submitting up-coded claims to Medicare related to administration of the COVID-19 vaccine. Schenker and the two facilities provided higher-level CPT codes for services not actually provided, charging, e.g., for an office visit or exam when the patient only actually received a vaccine or a COVID test. EDNYMarch 28, 2022
A Pennsylvania-based psychiatrist and his wife have agreed to pay $3 million in the largest recovery against a single psychiatrist ever in the history of the U.S. Department of Labor – Office of Worker’s Compensation Programs (OWCP). From 2013 to 2021, Dr. Harry Doyle and his wife and sole employee, Sonya, allegedly billed OWCP for services that weren’t rendered, submitted double-billed and upcoded patient claims, and falsified patient records to reflect their false billing. As part of the settlement, they will be excluded from participating in federal healthcare programs for 25 years. USAO EDPAMarch 3, 2022
New York-based ophthalmologist Ameet Goyal, M.D., who owned and operated Rye Eye Associates, has been sentenced to 8 years in prison and ordered to pay $3.6 million in forfeiture as well as $3.6 million in restitution for submitting $3.6 million in upcoded charges to Medicare, private insurers, and patients between 2010 and 2017. While facing charges for healthcare fraud in 2020, Goyal also falsely certified that he was not facing any criminal charges in order to obtain over $600,000 in loans from the Paycheck Protection Program. USAO SDNYAs Whistleblowers and Quality Care Advocates, Hospitalists are the Conscience of Healthcare
Posted 02/28/22
