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Upcoding

This archive displays posts tagged as relevant to upcoding in healthcare billing. You may also be interested in our pages:

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September 3, 2020

Having previously pleaded guilty to healthcare fraud and related charges, Arizona urgent care provider UCXtra Umbrella, LLC, which did business as "Urgent Care Extra," was sentenced to pay restitution of $12.5 million.  Defendant admitted that it ordered tests and procedures that were not medically necessary and that its billings intentionally overstated the complexity of services to patients in order to receive inflated reimbursements from private insurance companies. USAO AZ

Windfall to Health Insurers Due to COVID-19 Is Not Yet Resulting in Resolution of FCA Risk Adjustment Cases

Posted  08/21/20
By Edward Baker
As health insurers book record profits during the COVID-19 pandemic due to a dramatic decline in elective surgeries and procedures, this seems like a good time to ask about the status of False Claims Act litigation against Medicare Advantage Organizations (MAOs) relating to risk adjustment fraud.  Given the dire shortfall in state and federal money to fight the pandemic, when will MAOs begin paying back the billions...

August 19, 2020

Metropolitan Jewish Health System Hospice and Palliative Care agreed to pay a total of $5.225 million resolve civil allegations that it billed Medicare and Medicaid for services rendered to hospice patients at heightened levels of care for which the patients did not qualify, in violation of the False Claims Act. A government investigation following the filing of a whistleblower complaint determined that defendant falsely claimed that some of its patients required heightened “continuous home care services” and “general inpatient services,” thereby entitling the defendant to artificially inflated reimbursements.  USAO ED NY

July 23, 2020

Progenity, Inc., f/k/a Ascendant MDx, Inc., has agreed to pay a total of $49 million to resolve allegations that the California-based clinical laboratory submitted false claims to Medicaid, the VA, TRICARE, and the Federal Employees Health Benefits Program (FEHBP) through different fraudulent schemes.  First, from 2012 to 2016, Progenity allegedly billed the programs for non-reimbursable prenatal tests using a reimbursable billing code.  Second, in claims originally brought by a whistleblower under the False Claims Act, the company was alleged to violate the Anti-Kickback Statue by providing improper incentives to physicians—including paying above fair market value for blood specimen “draw fees”, providing tens of thousands of dollars in free food and alcohol, and routinely reducing or waiving co-insurance or deductibles—in order to induce physicians to order their tests.  Approximately $35.9 million of the settlement proceeds will go toward resolving federal claims, with the remaining $13.1 million paid to different states.  AG NC; USAO SDCA; USAO SDNY

July 13, 2020

Longwood Management Company and 27 affiliated skilled nursing facilities have agreed to pay $16.7 million to resolve allegations raised by whistleblowers Judy Boyce, Benjamin Monsod, and Keith Pennetti in two separate qui tam filings, that six Longwood facilities knowingly submitted false claims to Medicare.  Between 2018 to 2012, Longwood allegedly pressured its rehabilitation therapists to increase the amount of therapy provided to Medicare Part A patients, regardless of medical necessity, so it could claim Ultra High levels of service, which are reimbursed at the highest rate.  As part of the settlement, Longwood will enter into a five-year Corporate Integrity Agreement, and Boyce, Monsod, and Pennetti will share a $3 million award.  DOJ; USDC CDCA

June 25, 2020

Georgia-based Piedmont Healthcare, Inc. has agreed to pay $16 million to resolve whistleblower-brought allegations that it violated the Anti-Kickback Statute and False Claims Act.  The relator in this case, a former Piedmont physician, alleged that between 2009 and 2013, Piedmont’s case managers overturned physician recommendations for outpatient care by submitting claims for more expensive inpatient care to Medicare and Medicaid.  Furthermore, when the healthcare system acquired the Atlanta Cardiology Group in 2007, it allegedly paid far above fair market value for a catherization lab that was partly owned by the practice group.  For bringing a successful enforcement action, the unnamed relator will receive a share of nearly $3 million of the settlement proceeds. USAO SDGA

Integra Med Analytics Loses Battle to Establish New Breed of Corporate Whistleblower Outsiders, Write Mary Inman and Max Voldman in RACMonitor

Posted  06/10/20
attorney headshots of Mary Inman and Max Voldman
Constantine Cannon whistleblower attorneys Mary Inman and Max Voldman updated their earlier reporting in RAC Monitor regarding the False Claims Act case brought by Integra Med Analytics against Texas-based hospital chain Baylor Scott & White.  At the end of May, the Fifth Circuit Court of Appeals upheld a Texas district court opinion dismissing the case. As we have earlier written, Integra alleged that the...

Data Analysts: a New Kind of Whistleblower to “Catch a Rogue,” write Gordon Schnell and Max Voldman in Stat News

Posted  03/20/20
data-analyst-on-laptop
On March 16, 2019, STAT published an article by Constantine Cannon whistleblower lawyers Gordon Schnell and Max Voldman about a new kind of whistleblower emerging: the data-driven whistleblower. The article, Data analysts: a new kind of whistleblower to ‘catch a rogue’?, discusses different courts’ reaction to False Claims Act cases brought by Integra Med Analytics, a “forensic analysis firm that studies...

January 15, 2020

TMJ & Orofacial Pain Treatment Centers of Wisconsin has agreed to pay $1 million to settle a qui tam suit alleging submissions of false claims to Medicare and TRICARE.  According to the anonymous whistleblower, who will receive an undisclosed share of the settlement, TMJ billed the government health programs for prosthetic devices as if they had been fabricated by in-house surgeons, when in fact they had been fabricated by an outside laboratory.  USAO EDWI

October 29, 2019

Encompass Health Corporation (EHC), f/k/a HealthSouth Corporation, has agreed to pay $4 million to resolve of improperly billing Medicare.  According to the DOJ, between 2008 and 2012, an inpatient rehabilitation facility owned by EHC had improperly assigned low Functional Independence Measure scores on Patient Assessment Instrument forms in a bid to receive higher reimbursements from Medicare.  USAO NV
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