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Upcoding

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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

February 7, 2019

Six people associated with a string of substance abuse treatment centers have been indicted for defrauding Ohio's Medicaid program of over $31 million. Ryan Sheridan, the owner and operator of the businesses, along with Jennifer Sheridan, Kortney Gherardi, Lisa Pertee, Thomas Bailey, and Arthur Smith, allegedly submitted claims that were false on a number of fronts, including but not limited to: billing without proper documentation, for medically unnecessary services, provided by unqualified persons, and upcoded to a more costly service. Altogether, 134,744 false claims were submitted for more than $48.5 million in services. USAO NDOH

December 19, 2018

A vascular surgeon and his practice group, Dr. Irfan Siddiqui and the Heart and Vascular Institute of Florida (HAVI), have agreed to pay $2.23 million to settle a False Claims Act brought by a whistleblower, Lois Hawks, who had been a patient of the doctor.  Defendants were alleged to have submitted false claims for vein ablation services that were not medically necessary, were performed by unqualified personnel, or were based on medical records containing false diagnoses and symptoms.  In addition, defendants were alleged to have upcoded evaluation and management service claims.  Ms. Haws will receive a relator's share of $446,000USAO MDFL

Listen: Expected Dismissal of Providence Health Upcoding Suit

Posted  12/7/18
Constantine Cannon partner Mary Inman joins the RAC Monitor “Monitor Monday” podcast to comment on the government’s decision to decline to intervene in a $188.1 million whistleblower lawsuit Med Analytics, LLC filed against Providence Health (now known as Providence St. Joseph) alleging Providence upcoded diagnoses it submitted to government health programs for reimbursement. Several reports have indicated the...

November 6, 2018

An Indiana-based dental care practice and admin support company have agreed to pay a total of $5.139 million to settle allegations they violated the federal and Indiana state False Claims Acts. According to whistleblower and qui tam plaintiff Dr. Jihaad Abdul-Majid, between 2009 and 2013, ImmediaDent of Indiana, LLC and Samson Dental Partners, LLC allegedly billed Indiana's Medicaid program for procedures that were either upcoded (i.e. represented to be more serious and more expensive than they actually were), were not actually performed, or were not medically necessary. Samson Dental Partners is additionally accused of violating Indiana’s law prohibiting the corporate practice of dentistry. Because the companies refused oversight proposed during settlement, they have now been classified as "high risk" to federal healthcare programs. IN AG; USAO WDKY

October 1, 2018

HealthCare Partners Holdings LLC, a DaVita entity, will pay $270 million to settle allegations arising from DaVita's collection and submission of diagnosis data for Medicare Advantage beneficiaries to whom DaVita provided healthcare services.  HealthCare Partners, an independent physician association, allegedly instituted practices that caused the submission of incorrect diagnosis codes - diagnosis codes that increased payments from CMS to the MAOs, and then from the MAOs to DaVita/HealthCare Partners.  DaVita had voluntarily disclosed some practices, including improper medical coding guidance provided to physicians.  In addition, a whistleblower, James Swoben, alleged in a False Claims Act qui tam case that HealthCare Partners had engaged in improper "one-way chart reviews," which added diagnosis codes identified from the review of patient charts, but did not delete previously-submitted diagnosis codes that were not supported by the patient charts. Swoben will receive a whistleblower reward of $10,199,100. DOJ

Catch of the Week — Health Management Associates

Posted  09/27/18
Health Management Associates, LLC (“HMA”), a former hospital chain now part of Community Health Systems, agreed on September 25th to a $260 million settlement to resolve allegations of false billing and kickbacks alleged in eight qui tam cases under the False Claims Act (“FCA”). HMA was a hospital chain headquartered in Tampa, Florida that was acquired by Community Health Systems Inc., a major U.S. hospital...

September 26, 2018

A Connecticut-based doctor, Helar Campos, has agreed to pay $99,912 to settle claims of violating the False Claims Act. The alleged fraud occurred over a span of three years from 2009 to 2012 and involved upcoding claims for doctor visits to Medicare and Medicaid. USAO CT

Inman writes on whistleblower case brought by outsider

Posted  08/30/18
Constantine Cannon partner Mary Inman published an article in RAC Monitor about a lawsuit brought against Providence Health & Services and its consultant J.A. Thomas and Associates LLC (JATA) by Integra Med Analytics LLC, a data analysis firm that uses statistical analysis of publicly available data to attempt to uncover and prove fraud. Integra alleged that it analyzed seven years’ worth of publicly-available...
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