United States: Orthopedic Practice Pays $1,537,796 To Resolve Allegations Of False Claims Submitted To Federal And State Programs For Medical Services

The orthopedic practice and its physicians paid $1,537,796 to settle civil claims stemming from allegations that they submitted false claims to Medicare, Medicaid, the Department of Veterans Affairs, and TRICARE.

Following an internal review and audit, the practice discovered irregularities in prior billing processes and practices. The practice proactively contacted the United States government to voluntarily disclose the billing irregularities and documentation deficiencies they had identified. The practice cooperated with the government and provided access to both privileged and non-privileged internal documentation, audit, and medical records, as well as access to their consultant statistician.

The voluntary disclosure and investigation revealed that the government had certain civil claims against the practice for false claims arising under Medicare, Medicaid, TRICARE, and the Veterans Health Administration. Specifically, that the practice had improperly billed the health care programs for the following: (i) physician extenders without documentation in progress notes to support billing, evaluation, and management codes; (ii) durable medical equipment, prosthetics, orthotics, and supplies ("DMEPOS") where bills had incorrect CPT codes, where documentation did not support proof of delivery of the DMEPOS, and where documentation did not support that the DMEPOS was ordered or medically necessary for the patient; (iii) evaluation and management codes related to hospital consults that were not supported by documentation in progress notes; and (iv) physical therapy where the documentation did not support CPT codes billed and or the number of physical therapy units billed.

A few thoughts. That is a lot of money and in order to resolve the matter the practice provided the government with access to privileged information. If practices regularly audit their billing and coding processes and practices, problems like this will be identified early and disclosures and investigations may be able to be avoided.

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