Category: Compliance

Physician Admits Upcoding of Services

SYRACUSE, NEW YORK – Ahmad M. Mehdi and his medical practice, Ahmad M. Mehdi, M.D., P.C. (“Mehdi”), agreed to pay a total of $900,000 to resolve civil claims for up-coding billings for some medical services, billing for smoking cessation counseling services that were not adequately documented, and allegedly improper prescribing of opioids, announced United States Attorney Carla B. Freedman.

Mehdi operates a general medical practice with offices in Groton and Tully, New York.  According to the settlement agreement, between January 1, 2012, and September 17, 2018, Mehdi caused false claims to be submitted to federal healthcare programs by billing for some services at a higher rate of reimbursement than it would be entitled to for the service actually provided, a scheme commonly referred to as “upcoding.” Mehdi also submitted billing to federal healthcare programs for some smoking cessation counseling services that were not sufficiently documented.  This settlement also resolves claims that Mehdi violated the Controlled Substances Act between April 1, 2018, and December 31, 2020, by prescribing opioids outside the usual course of professional practice to three patients.  Mehdi has agreed to pay $331,250 to the United States to resolve all of these claims.  Mehdi will also pay $568,750 to the State of New York pursuant to the terms of a separate agreement.

“Providers who increase their own profits by over-billing for medical care increase medical costs for all of us and drain critical funds from Medicare and other government health programs,” said U.S. Attorney Freedman.  “We will continue to hold accountable medical professionals who undermine our healthcare system by over-billing for care.”

https://www.justice.gov/usao-ndny/pr/central-new-york-doctor-settles-improper-billing-and-controlled-substance-act-claims

What OIG allegedly found:

With respect to the six high-risk groups covered by our audit, most of the selected diagnosis codes that Highmark submitted to CMS for use in CMS’s risk adjustment program did not comply with Federal requirements. For 66 of the 226 sampled enrollee-years, either the medical records validated the reviewed HCCs, or we identified another diagnosis code (on CMS’s systems) that mapped to the HCC under review. However, for the remaining 160 enrollee-years, the diagnosis codes were not supported in the medical records. These errors occurred because the policies and procedures that Highmark had to prevent, detect, and correct noncompliance with CMS’s program requirements, as mandated by Federal regulations, could be improved. As a result, the HCCs for these high-risk diagnosis codes were not validated. On the basis of our sample results, we estimated that Highmark received at least $6.2 million of net overpayments for 2015 and 2016.1

https://oig.hhs.gov/oas/reports/region3/31900001.pdf

ALBANY, NEW YORK – North Country Neurology, P.C., a physician-owned medical practice located in Watertown, New York, has agreed to pay $850,000 for what it admitted was “improper” and “reckless” billing to the federal government for medical services, announced United States Attorney Carla B. Freedman.

“The integrity of our federal health care system depends on accurate and honest billing by medical providers,” said United States Attorney Freedman.  “While North Country Neurology will pay a steep price for submitting false claims for payment to Medicare, I commend the practice and its management for accepting responsibility for its past actions and for implementing forward-looking compliance measures in response to our investigation to assure systems are in place to facilitate and promote ethical and legal conduct in the future.”

North Country Neurology employed physicians and a physician assistant who rendered care to Medicare beneficiaries.  In certain circumstances, Medicare allows practices to bill for services rendered by a non-physician practitioner (NPP), including a physician assistant, “incident to” the services that are personally rendered by a physician.  These services, even though not personally rendered by a physician, may be billed in a physician’s name if several requirements are met.  One such requirement is that a physician directly supervise the NPP rendering the services, meaning that a physician is present in the office suite and immediately available to furnish assistance and direction throughout the procedure.  Although Medicare will reimburse practices for certain procedures rendered by NPPs without a physician’s direct supervision, such services are reimbursed at a lesser rate than service rendered or directly supervised by a physician.

North Country Neurology admitted that, on 120 occasions from September 2015 through June 2019, it “submitted or caused to be submitted claims for payment to Medicare that improperly listed a physician as the rendering provider for services rendered by a physician assistant when no physician was physically present in the office and immediately available to furnish assistance and direction throughout the performance of the procedure.”  The practice further admitted that it “knew or should have known the requirements of incident-to billing and that it was improper to submit claims to Medicare in a physician’s name for services rendered by an NPP when no physician was in the office” because, among other reasons, its billing company had informed the practice’s owner of separate incident-to billing violations several years earlier.

https://www.justice.gov/usao-ndny/pr/watertown-medical-practice-pay-850000-resolve-false-claims-act-allegations

On March 2, 2022, Metroplex Pain Consultants, LLC (Metroplex) and Dr. Steven Casey (Dr. Casey), Dallas, Texas, entered into a $110,748.12 settlement agreement with OIG. The settlement agreement resolves allegations that Metroplex submitted claims for services purportedly rendered by Dr. Casey during a time period when Dr. Casey was not at his office. Additionally, OIG alleged that Metroplex and Dr. Casey submitted claims to Medicare for spinal facet joint injections, which amounts exceeded five in a rolling 12-month period. OIG’s Office of Audit Services and Office of Counsel to the Inspector General, represented by Gregory Becker, collaborated to achieve this resolution.

https://oig.hhs.gov/fraud/enforcement/metroplex-pain-consultants-and-dr-steven-casey-agreed-to-pay-110000-for-allegedly-violating-the-civil-monetary-penalties-law-by-submitting-claims-dr-casey-did-not-perform-or-directly-supervise-and-claims-for-excessive-services/

On November 30, 2021, Meir Daller, MD (Dr. Daller), Fort Myers, Florida, entered into a settlement agreement with OIG in which he agreed to pay $455,400 and be excluded from participation in all Federal health care programs for three years under 42 U.S.C. 1320a-7a and 42 U.S.C. 1320a-7(b)(7). The settlement agreement resolves allegations that Dr. Daller submitted or caused to be submitted the following: (1) claims for cystourethroscopy with dilation of urethral stricture where no stricture was present that necessitated urethral dilation; (2) claims for urodynamics testing that was ordered on a routine periodic basis, not out of medical necessity; and (3) claims for evaluation and management (E&M) services related to in-office testosterone injections that were: (i) submitted in conjunction with claims for the testosterone injections, using modifier 25, where no significant and separately identifiable service other than the testosterone injection took place; and (ii) submitted alone where the patient received an in-office testosterone injection but no evaluation or management of the patient took place that justified the billing of an E&M code. OIG’s Division of Data Analytics and Office of Counsel to the Inspector General, represented by Senior Counsels Michael Torrisi and Srishti Sheffner with the assistance of Chief Investigator Amber Mahmood and Program Analyst Mariel Filtz, collaborated to achieve this resolution.

https://oig.hhs.gov/fraud/enforcement/dr-meir-daller-agreed-to-pay-455000-and-be-excluded-for-3-years-for-allegedly-violating-the-civil-monetary-penalties-law-by-submitting-false-and-medically-unnecessary-claims-associated-with-urology-services/

What OIG allegedly found:

Humana did not submit some diagnosis codes to CMS for use in the risk adjustment program in accordance with Federal requirements. First, although most of the diagnosis codes that Humana submitted were supported in the medical records and therefore validated 1,322 of the 1,525 sampled enrollees’ HCCs, the remaining 203 HCCs were not validated and resulted in overpayments. These 203 unvalidated HCCs included 20 HCCs for which we identified 22 other, replacement HCCs for more and less severe manifestations of the diseases. Second, there were an additional 15 HCCs for which the medical records supported diagnosis codes that Humana should have submitted to CMS but did not. Thus, the risk scores for the 200 sampled enrollees should not have been based on the 1,525 HCCs. Rather, the risk scores should have been based on 1,359 HCCs (1,322 validated HCCs + 22 other HCCs + 15 additional HCCs). As a result, we estimated that Humana received at least $197.7 million in net overpayments for 2015. These errors occurred because Humana’s policies and procedures to prevent, detect, and correct noncompliance with CMS’s program requirements, as mandated by Federal regulations, were not always effective.

https://oig.hhs.gov/oas/reports/region7/71601165.pdf

What OIG allegedly found:

OIG found that some of the diagnosis codes that Essence submitted to CMS for use in CMS’s risk adjustment program did not comply with Federal requirements. For 75 of the 218 enrollee-years, the diagnosis codes (48 acute stroke and 27 major depressive disorder) that Essence submitted to CMS either were not supported in the medical records (70) or could not be supported because Essence could not locate the medical records (5).

https://oig.hhs.gov/oas/reports/region7/71701170.asp