CityMD, a company that manages over 80 urgent care clinics in and around New York City, has settled allegations that it billed Medicare for more expensive services than were actually performed, and that it billed Medicare under the names of doctors who did not actually perform the services. Under the terms of the settlement, CityMD also accepted responsibility for its conduct.
In its settlement agreement, CityMD admitted to a variety of fraudulent schemes. City MD billed Medicare for longer or more complicated services than it actually provided to patients or were supported by the documentation in a patient’s medical records. Generally, this involved exaggerating the level of an “evaluation and management” CPT code. Evaluation and management codes are broken out into five categories, ranging from quick, simple visits, to something akin to a severe emergency room visit. Variables such as whether the patient is new, elapsed time, complexity, and necessary follow-up procedures determine which level of code is appropriate. On the lower end of a spectrum, only 5-10 minutes of care are required; this ranges to over an hour of care required under the most severe codes.
CityMD also sought reimbursement for services performed by doctors who were not enrolled with the Medicare program, in violation of Medicare regulations. Physicians are required to sign a form certifying that the services they are billing for were rendered by them. Services performed by physicians who are not enrolled in the Medicare program are not reimbursable at all. To track rendering physicians, and their Medicare program enrollment, CMS uses National Provider Identification (NPI) numbers, 10 digit identifying numbers that are assigned to all licensed doctors. To bill for services performed by those physicians, CityMD used the credentials, and NPI numbers, of other employed physicians who were enrolled in the Medicare program, but did not actually provide the services.
The case was brought by a whistleblower under the “qui tam” provisions of the FCA. The whistleblower will receive a reward of 15%-25% of the $6.6M settlement.
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