The False Claims Act is drafted to prevent unlawful advancements of money from the federal government to contractors or entities doing business on behalf of federal programs. In recent years, one of the most frequent victims of fraud under the FCA is the Medicare program, which provides healthcare coverage for eligible individuals based on age. The similar need-based healthcare program, Medicaid, also faces regular submissions for fraudulent and inflated claims and is often successful in recouping money from unscrupulous clinics, physicians, and pharmaceutical corporations.
A physician can trigger liability under the FCA for submitting claims to Medicare that are not entirely congruent with the actual type, duration, or quality of service rendered at the time of the patient interaction. One of the most common phenomena involving Medicare fraud involves a system known as “upcoding.” When a physician submits a claim for reimbursement, he uses a specific code found in the Physician Fee Schedule to bill for the particular service. These codes are used universally for all Medicare claims across the United States. When an office engages in “upcoding,” it enters codes for services that are more expensive than the service actually rendered. In some cases, the “upcode” is for a more costly service than the patient received, whereas in other cases the “upcode” is for a service never rendered.
Upcoding by Unqualified Personnel
One alarming type of upcoding involves the use of unqualified nurses or assistants to perform tasks reserved for a physician. In a recent case out of Florida, a Tampa-area vein clinic paid $400,000 to settle claims it allowed unqualified staff members to conduct services that should have been conducted by a doctor. Under Medicare rules, if a certain procedure is to be performed by a physician, a patient cannot receive reimbursement for that service if it was actually performed by a nurse or another member of the staff.
In the case of U.S. ex rel. Lovell v. Ravi Sharma, M.D. and Premier Vein Centers, a whistleblower filed a lawsuit after a former office manager felt uneasy billing physician time for services performed by nurses. More specifically, the whistleblower alleged a routine practice wherein nurses and other staff members would meet with patients and perform intake interviews, followed by instruction from the physician to bill for a physician office visit. In addition, allegations detailed direction from the physician instructing the office manager to perform varicose vein injections on patients when he was not even in the office. Additionally, many of these injections, including several ultrasound imaging procedures, were completely unnecessary and prescribed for purposes of receiving inflated Medicare reimbursements.
The whistleblower in this case is set to receive $72,000 for her willingness to come forward. In addition to its agreement to remit $400,000, the physician in charge has entered into a three-year integrity agreement with the Department of Health and Human Services. The U.S. Attorney for the Middle District of Florida, who worked on the case after the government’s decision to intervene, stated, “We are pleased to announce this very favorable resolution of our claims against this provider…Again, it demonstrates our commitment to civil healthcare fraud enforcement in our district.”
If you work in the healthcare industry, you may be familiar with the office structure detailed above. If you are aware of doctors in your office instructing staff and personnel to perform certain tasks you believe may be reserved for physicians only, consider contacting a reputable whistleblower attorney today.