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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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July 24, 2019

Pennsylvania-based Eagleville Hospital has agreed to pay $2.85 million to settle allegations of defrauding Medicare, Medicaid, and the Federal Employees Health Benefits Program.  According to an anonymous relator, Eagleville violated the False Claims Act between 2011 and 2018 by submitting claims for substance abuse patients improperly admitted for high paying, hospital-level detoxification treatments.  The whistleblower will receive $500,000 of the recovery.  USAO EDPA

Question of the Week — Should providers who defraud Medicare be excluded from it?

Posted  06/18/19
Fortune Cookie with Message with Message Saying "Not Eligible for Medicare!"
Sometimes, though rarely, when a medical provider settles a False Claims Act case or is found to have violated the FCA at trial, they are excluded from participating in healthcare programs as a condition of resolving the case. Often, this is a limited-time ban that is meant to incentivize providers to follow Medicare’s rules in the future and to deter other providers from committing fraud. Between Medicare,...

June 11, 2019

A physical therapy center, its owner, and four nursing facilities in the Chicago area have settled an intervened qui tam suit that alleged that they upcoded patient Resource Utilization Group (RUG) scores, in violation of the False Claims Act, in order to increase Medicare payments.  Quality Therapy & Consultation Inc and owner Francise Parise allegedly worked in conjunction with Carlton at the Lake Inc, Ridgeview Rehab and Nursing Center, Lake Shore Healthcare and Rehabilitation Centre LLC, and Balmoral Home Inc to manipulate the RUG scores, which indicate the level of skilled nursing care each patient requires.  By upcoding the scores, the defendants allegedly claimed higher reimbursement rates from Medicare.  As part of the settlement, each of the facilities will pay between $1 and $4 million, and Parise will pay $160,000, for a combined recovery of $9.7 millionUSAO NDIL

May 31, 2019

Oklahoma Heart Hospital, LLC and Oklahoma Heart Hospital South, LLC (collectively “OHH”), have agreed to pay $2.8 million to resolve a qui tam suit by a former employee, which alleged that OHH violated the federal and state False Claims Acts and defrauded Medicaid by submitting claims for outpatient procedures as if they were inpatient procedures.  Though multiple allegations were raised in the lawsuit, only the allegation involving the upcoded claims was intervened by the government; the other allegations will be dismissed as part of the settlement.  USAO WDOK

May 9, 2019

Carolina Physical Therapy and Sports Medicine, Inc. agreed to pay $790,000 to settle a whistleblower lawsuit alleging the company knowingly submitted false claims to Medicare and TRICARE. According to former employee Hilary Moore, Carolina PT submitted claims for group physical therapy services that were billed as though they were one-on-one sessions. Additionally, claims for certain services performed by physical therapy assistants were billed as though they were performed under the supervision of qualified therapists. For exposing the fraudulent conduct, Moore will receive a relator’s share of $142,200USAO SC

March 29, 2019

CareWell Urgent Care of Rhode Island, P.C., and Urgent Care Centers of New England Inc. have agreed to pay $2 million to settle a qui tam suit brought on by a former employee, Aileen Cartier. In violation of the False Claims Act, CareWell had falsely inflated the level of services provided and failed to identify service providers in claims submitted to Medicare, Massachusetts and Rhode Island Medicaid, and the Massachusetts Group Insurance Commission (GIC) between 2013 to 2018. For bringing on the suit, Cartier will receive a 17% relator's share. USAO MA

March 27, 2019

In the second largest resolution of a Medicaid fraud case based in Washington State, CareOne Dental Corporation and its owners will pay $1 million to settle allegations of violating Washington's Medicaid False Claims Act. According to the AG's office, CareOne and defendants Dr. Liem Do and Dr. Phuong-Oanh Tran defrauded Medicaid by using higher paying codes, masking ineligible services as eligible services, and billing for services the practice didn't even provide. Ultimately, the defendants racked up about $1 million over the course of four years. AG WA

February 21, 2019

Hooshang Poor, a doctor of geriatric medicine based in Newton, Massachusetts, has agreed to pay $680,000 to resolve claims under the False Claims Act that he knowingly submitted inflated charges to Medicare and the Massachusetts Medicaid program.  Dr. Poor was alleged to submit bills with false procedural codes that overstated the length, extent, and scope of services that he furnished to nursing home residents, and misrepresented services provided by non-physician employees.  USAO Mass.

Data Whistleblower Case Raises Question of What is a Public Disclosure

Posted  02/21/19
Rows of chairs with people waiting in hospital billing office
As regular readers know, we have been closely tracking the progress of data analysis firm Integra Med Analytics’ whistleblower lawsuit under the False Claims Act against Providence Health and its consultant J.A. Thomas and Associates, Inc. (JATA).  The case alleges a conspiracy between Providence and JATA to upcode for specific Major Complications or Comorbidities (MCCs). This case is part of a growing number of...

February 14, 2019

Prime Healthcare Services and its CEO Prem Reddy, will pay $1.25 million to settle claims under the False Claims Act that two Prime Healthcare hospitals in Pennsylvania, Roxborough Memorial Hospital and Lower Bucks Hospital, billed Medicare for patients who were admitted when they could have been treated on an outpatient basis, and up-coded patient diagnoses to increase Medicare payments.  The investigation was initiated by an anonymous whistleblower identified as a former employee of the Roxborough hospital.  USAO ED PA
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