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Upcoding

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TeamHealth to Pay $60M to Settle Whistleblower Charges

Posted  02/7/17
By the C|C Whistleblower Lawyer Team U.S. hospital service provider TeamHealth Holdings agreed to pay $60 million to settle charges its predecessor company IPC Healthcare Inc. violated the False Claims Act by billing Medicare, Medicaid, the Defense Health Agency and the Federal Employees Health Benefits Program for higher and more expensive levels of medical service than were actually performed. See DOJ Press...

HHS-OIG Continues to Uncover Unfounded Malnutrition Claims in Medicare Data

Posted  01/25/17
By the C|C Whistleblower Lawyer Team Inaccurate medical coding of malnutrition in seniors is a multi-billion dollar problem for Medicare, the federal health insurance program that primarily provides coverage to people aged 65 and older. As obscure as it sounds, it’s also an issue for the average American taxpayer, whose tax dollars are wrongly paid out to hospitals clever—or careless—enough to falsely claim...

January 13, 2017

Massachusetts-based ambulance company Medstar Ambulance Inc., including four subsidiary companies and its two owners, Nicholas and Gregory Melehov, agreed to pay $12.7 million to resolve allegations that they violated the False Claims Act by submitting false claims to Medicare for ambulance transport services. According to the government, Medstar routinely billed for services that did not qualify for reimbursement because the transports were not medically reasonable and necessary, billed for higher levels of services than were required by patients’ conditions, and billed for higher levels of services than were actually provided. The allegations originated in a whistleblower lawsuit filed under the qui tam provisions of the False Claims Act by Dale Meehan, a former employee in Medstar’s billing office. Mr. Meehan will receive a whistleblower award of roughly $3.5 million. DOJ

Health Care Fraud Alert: Diagnosis Code Upcoding

Posted  08/22/16
By Rosie Dawn Griffin Medicare fraud takes many forms, but a persistent scheme in the inpatient context—where the amount of government reimbursement can be based, in addition to procedure costs, on patients’ overall health—involves “upcoding” inpatient diagnosis-related-group (DRG) codes to make individual patients appear sicker, and therefore more costly to treat, than they actually are. Fraudsters...

August 8, 2016

The Estate of Dr. Kenneth Michael Rice and Texas-based physician practice management group UMC Physicians agreed to pay roughly $3.3 million to settle charges of violating the False Claims Act for billing Medicare/Medicaid for in-person evaluation and management services at the higher physician fee rate when the services were not provided by physicians.  They also allegedly billed normal evaluation and management services to Medicare at the higher critical-care rate.  DOJ (NDTX)

July 7, 2016

MD2U Holding Company agreed to pay $3.3 million and a percentage of its net income over the next five years to settle charges they violated the False Claims Act by submitting false medical claims to Medicare and other government health care programs, altering records to support false claims and providing services that were medically unnecessary.  Specifically, the government alleged MD2U submitted false billings for patients who were neither homebound nor home-limited; improperly billed the government for medically unnecessary visits; billed government health care programs at the highest payment codes (upcoding) when a lower code would have been more appropriate; and cloned medical records (a cut, copy, paste electronic program) in order to justify patient visits.  The company admitted being liable to the government for roughly $21.5 million.  DOJ

May 18, 2016

Missouri physician Randall E. Meyer pleaded guilty to (and agreed to pay roughly $75,000) violating the False Claims Act.  Meyer, a surgeon with Central Missouri Cardiology, P.C., admitted claiming the percentage of patients’ lesions and stenosis in their arteries was 70 percent or greater when it was substantially less.  The health care benefit programs would not have reimbursed claims if the programs had known Meyer was inflating the percentage of patient lesion and stenosis.  DOJ (W.D.MO)

April 18, 2016

Georgia dermatologists Margaret Kopchick and Russell Burken and their practice group, Toccoa Clinic Medical Associates, agreed collectively to pay $1.9 million to settle claims that they violated the False Claims Act by billing Medicare for evaluation and management (E&M) services that were not permitted by Medicare rules.  According to the government, Drs. Burken and Kopchick’s improperly billed for E&M services along with procedures where no significant and separately identifiable service was performed, and upcoded E&M services to higher levels than were appropriate, leading to overpayments by Medicare.  DOJ (NDGA)

March 8, 2016

A Connecticut psychiatrist will pay $404,798 to settle a civil False Claims Act lawsuit alleging that she submitted false claims for payments to Connecticut’s Medicaid program. The state alleged that, from March 2010 to September 2013, while operating a private practice in Mansfield, Dr. Panoor submitted upcoded claims indicating that she provided Medicaid patients with both group counseling and either individual psychotherapy or a detailed examination on the same dates of service when, in fact, she did not provide psychotherapy or detailed examination sessions but instead provided medication management services or a brief meeting with the patient for the purpose of monitoring or changing a patient’s drug prescription – services that are coded, and thus reimbursed, at lower payment rates.
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