Upcoding

August 4, 2014

Community Health Systems (CHS), the nation’s largest operator of acute care hospitals, agreed to pay $98 million to resolve multiple whistleblower lawsuits alleging the company billed government health care programs for inpatient services that should have been billed as outpatient or observation services. According to the government, CHS engaged in a corporate-driven scheme to increase inpatient admissions of Medicare, Medicaid and TRICARE (military) beneficiaries over the age of 65 who originally presented to the emergency departments at 119 CHS hospitals.Whistleblower Insider

March 18, 2014

American Family Care Inc., a network of walk-in medical clinics with offices in Alabama, Tennessee and Georgia, agreed to pay $1.2M to resolve allegations under the False Claims Act that it knowingly submitted claims to Medicare for outpatient office visits that were billed at a higher rate than was appropriate. The settlement resolves a qui tam lawsuit filed by a former employee of American Family Care under the whistleblower provision of the False Claims Act. DOJ

December 18, 2015

Thirty-two hospitals in 15 states agreed to pay more than $28 million to settle charges they violated the False Claims Act by submitting false claims to Medicare for minimally-invasive kyphoplasty procedures used to treat certain spinal fractures often arising from osteoporosis.  According to the government, the settling hospitals billed Medicare for these procedures on a more costly inpatient basis when they should have been billed on a less costly outpatient basis.  The government has now reached settlements with more than 130 hospitals totaling approximately $105 million to resolve allegations of overcharging Medicare for kyphoplasty procedures.  The 15 current settling hospitals include: The Cleveland Clinic (Ohio); Citrus Memorial Health System (Florida); Cullman Regional Medical Center (Alabama); Martin Memorial Medical Center (Florida); MultiCare Tacoma General Hospital (Washington); Norwalk Hospital (Connecticut); Princeton Community Hospital Association (West Virginia); Sacred Heart Medical Center (Washington); Sarasota Memorial Hospital (Florida); Spartanburg Regional Health Services District Inc. (South Carolina); St. Cloud Hospital (Minnesota); Tampa General Hospital (Florida); 5 hospitals affiliated with Community Health Systems Inc. (Tennessee); 5 hospitals affiliated with Tenet Health Care Corporation (Texas); 5 hospitals formerly owned and operated by Health Management Associates (Florida); 3 hospitals affiliated with BayCare Health System (Florida); and 2 hospitals affiliated with Banner Health (Arizona).  In addition, the government previously settled with Medtronic Spine LLC, the corporate successor to Kyphon Inc., for $75 million to settle allegations the company caused false claims to be submitted to Medicare by counseling hospital providers to perform kyphoplasty procedures as inpatient rather than outpatient procedures.  All but 3 of the current settlements originated in a whistleblower lawsuit filed by Craig Patrick, a former Kyphon reimbursement manager, and Charles Bates, a former Kyphon sales manager for Kyphon.  They will receive a whistleblower award of roughly $4.75 million from the proceeds of the government’s recovery.  DOJ

September 10, 2015

The Washington Attorney General announced a suit against CareOne Dental Corporation and related individuals for Medicaid fraud. The suit alleges that the defendants systematically billed Medicaid for non-covered services which they misrepresented in their billings, “upcoded” services (more expensive versions of what they actually performed), and services they simply didn’t provide. The Attorney General’s Office currently estimates at least 20 percent of the claims CareOne Dental presented to Medicaid from January 2011 to June of 2015 were fraudulent, which would amount to approximately $1 million in single damages. WA

June 18, 2015

Connecticut commenced a case under that state’s False Claims Act against the co-owners of a psychiatric clinic alleged to have submitted false claims to the state’s Medicaid program, Connecticut Medical Assistance Program (CMAP), from January 2010 through December 2014. According to the complaint, the defendants illegally submitted false claims for reimbursement while knowingly retaining and concealing the overpayment. The psychiatrist is alleged to have engaged in a systemic practice of knowingly “upcoding” the claims for reimbursement she submitted to the CMAP. For example, as the complaint alleges, she routinely double, triple, and in some cases quadruple-booked appointments for her Medicaid patients, then submitted CMAP using a reimbursement code, which required her to see the patient for approximately 75 to 80 minutes when, in fact, she saw each patient for as little as 5-10 minutes. The state’s complaint identifies 113 days where the psychaitrist billed the CMAP for more than 24 hours of service. Both defendants are also alleged to have attempted to conceal from state auditors the existence of databases that contained information which would have established evidence that the claims were false. CT

May 6, 2015

New York Attorney General Eric T. Schneiderman announced that Carewell Ambulette, Inc. and its owner, Kurien Palliankal have pleaded guilty to stealing more than $200,000 from the New York Medicaid program. Palliankal will be sentenced to six months in jail, followed by five years of probation, and will also be required to pay full restitution to Medicaid. Carewell will be fined $10,000. From July 2006 through March 2010, Palliankal and Carewell defrauded the Medicaid system by doctoring the request forms received from the medical providers. These forms authorized taxi service, but Palliankal changed the forms to appear as though they authorized the more expensive ambulette service, which Medicaid pays at a rate four times higher than taxi service. NY