The Jacksonville Center for Reproductive Medicine (JCRM) recently settled with the Department of Justice amid allegations it billed the government for fertility services at rates above and beyond those allowable under TRICARE guidelines.
TRICARE is a government-funded healthcare insurance program covering military personnel and their families. Under its guidelines regarding assisted reproductive technology, an enrollee or spouse may be covered for the following infertility services:
-Infertility occurring as a result of an injury or accident sustained by either the male or female. Coverage is limited to surgical correction of the issue, if possible.
-Diagnostic testing of both male and female.
-Correction or treatment of male reproductive issues caused by organic factors.
Likewise, practitioners in any field are required to bill appropriate rates with regard to the personnel actually treating the patient. For instance, the most costly visits – those with physicians – are only to be billed when the physician and patient actually meet and discuss the ongoing issue. Meetings with nurses or physician assistants must be billed at a lower rate.
According to the Department of Justice, JCRM treated a number of TRICARE military families facing infertility. However, it unlawfully overbilled those patients using the well-known system of upcoding, which involves entering billing codes for more costly services than those actually rendered.
Details of the case against JCRM
According to the allegations set forth in a Department of Justice press release on April 10, 2015, JCRM is alleged to have falsely upcoded for infertility treatments offered to TRICARE patients from January 2009 through February 2013. During this time, the facility, at the direction of its sole practitioner, billed for reproductive services at rates much higher than allowable by TRICARE.
More specifically, the center is alleged to have misused the “incident to” provisions set forth by the TRICARE guidelines, which allow a practitioner to bill the fully compensable rate for treatment by assistants and nurses if doing so is “incident to” a course of treatment prescribed by the physician. Under the applicable regulations, nursing assistance may be billed at 100 percent of the physician’s rate if the service provided is “incident to services or supplies furnished as an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness.” To trigger the applicable “incident to” billing allowance, the following conditions must be met:
-Provider must be an employee of the physician.
-The initial visit for the condition must be performed by the physician.
-There must direct personal supervision by the physician.
-The physician must maintain an active role in the patient’s care.
Allegedly, the doctor’s involvement in this case with the patient’s course of treatment was so minimal, the “incident to” billing option was essentially inapplicable. Likewise, the practice is alleged to have billed for several “incident to” treatments that occurred when the doctor was not even in the facility.
In sum, the JCRM agreed to settle with the government for $98,838.98 in order to settle allegations. It has not admitted any liability in the matter.
The U.S. Attorney’s Office said in a statement, “TRICARE and other federal healthcare programs are dependent upon healthcare providers honestly reporting the work that they do….Claiming reimbursement for treatments not provided, or at higher rates than authorized by regulation, defrauds taxpayers and depletes limited funds available to provide medical care to deserving patients. By bringing False Claims Act cases such as this, we recover funds stolen from the government and deter others from attempting similar schemes.”
Contact Berger Montague today
If you are aware of unlawful billing practices in your place of employment or believe your provider may be charging excessive rates to your government health insurer, contact Berger Montague today.