Health Law Daily Upcoding, false statements lead to federal prison time for physician
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Thursday, January 23, 2020

Upcoding, false statements lead to federal prison time for physician

By Rebecca Mayo, J.D.

The penalties for submitting false claims may be higher, but the penalties for lying to state and federal investigators to cover up the false claims is even higher.

A physician from northern Iowa was sentenced to two months in federal prison for making false statements related to health care matters after lying in sworn answers to the United States Attorney about his billing practices. According to the Department of Justice, federal investigators and the Medicaid Fraud Control Unit discovered the fraud through the use of in-person surveillance and review of video surveillance. In addition to the prison sentence, the physician was ordered to pay a fine and entered into a settlement agreement with the HHS Office of Inspector General (OIG), under which he is required to pay $316,438.96 (Settlement Agreement, January 8, 2020).

False claims. In July 2016, a Medicare contractor sent an Iowa primary care physician a letter warning him that his billing patterns were significantly more expensive than other doctors. The physician had been billing 93 percent of his nursing home visits under the most intensive and expensive claim code, which required a doctor to spend 35 minutes at the patient’s bedside and on the patient’s facility floor or unit. Medicare typically paid more than $94 for these claims but would have paid no more than $32 if the visits had been a routine ten-minute visit billed under the least expensive claim code. The physician’s staff had a practice of submitting claims for reimbursement and then immediately shredding the notes for the nursing home patients the claims were based on. When the physician was asked for treatment notes and records for these services by the United States Attorney, the physician re-created fraudulent treatment notes.

Investigation. In June 2018 the United States Attorney for the Northern District of Iowa conducted a civil investigation about concerns that the physician was upcoding claims. The physician submitted sworn written answers to the United States Attorney, declaring that with respect to certain claims in 2017 and 2018, he had spent approximately 35 minutes for each of the 12 patients’ care at two nursing homes. He further claimed that on one particular day he had begun visiting nursing home patients at 7:30 a.m. and completed his visits with each patient at approximately 5:30 p.m. However, a federal agent had conducted in-person surveillance of the physician on that date and reported that the physician spent 47 minutes at the first nursing home and did not visit the second nursing home at all on that date. The Medicaid Fraud Control Unit discovered that the physician made other false statements about claims by reviewing videotaped surveillance. On one day the physician billed nine claims for services allegedly provided to nine patients, however the surveillance video showed that the physician was only at the nursing home for a total of 14 minutes.

Settlement. The physician entered into a settlement agreement in which he agreed to pay $316,438.96. Of this amount $107,980.59 was restitution to Medicare and $9,218.73 was restitution to Medicaid for economic losses caused by his commission of the offense. The physician also entered into a plea agreement in which he admitted to making false statements related to health care matters and he was sentenced to two months in prison and ordered to pay a fine.

MainStory: TopStory CMSNews BillingNews EnforcementNews FCANews FraudNews MedicaidNews PartANews ProgramIntegrityNews QualityNews

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