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.
Dr. Meir Daller Agreed to Pay $455,000 and Be Excluded for 3 Years for Allegedly Violating the Civil Monetary Penalties Law by Submitting False and Medically Unnecessary Claims Associated with rology 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.
Medicare Advantage Compliance Audit of Diagnosis Codes That Humana, Inc., (Contract H1036) Submitted to CMS
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.
Some Diagnosis Codes That Essence Healthcare, Inc., Submitted to CMS Did Not Comply With Federal Requirements
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).