Medicare Compliance & Reimbursement

Strengthen your understanding of MDM guidelines.

As you may know, the Department of Justice (DOJ) and the Office of Inspector General (OIG) are constantly involved in investigations relating to healthcare fraud and abuse. In his 2024 HEALTHCON presentation, “False Claims Act Case Involving the New MDM E/M Guidelines,” CJ Wolf, MD, M.Ed., CPC, CPC-I, COC, educator and compliance executive in Salt Lake City, explained what may be the first False Claims Act case involving the 2021 medical decision making (MDM) guidelines.

If your practice could use some expert insight into this case, keep reading, because Wolf also shared his expert take on how your practice can prevent a similar situation.

Take a Look at the Facts Surrounding the Case

What is the False Claims Act? The False Claims Act is a federal law that makes it a crime for any person or organization to knowingly make a false record or file a false claim to get money from federal healthcare programs such as Medicare and Medicaid. If found guilty, the person or organization might have to pay up to three times the government’s losses plus penalties.

The case: Two separate qui tam complaints (whistleblower complaints that can be filed under the False Claims Act) sparked an investigation into a Georgia-based urgent care chain spanning across four states. Approximately 50 to 60 clinics were under investigation for allegedly upcoding COVID-19-related encounters under the new evaluation and management (E/M) guidelines. The government ultimately concluded the following:

The “defendants who operate a chain of urgent care clinics in 4 States have defrauded the taxpayer by using the pandemic caused by COVID virus to reflexively claim that they are rendering a higher level of medical service than they are actually providing.”

The case ended up settling for $1.6 million.

Disclaimer: Settlements are not proof of liability or wrongdoing. The case discussed is based on allegations that the government investigated. The information presented is based on what’s public record.

“We have to make judgment calls right? But it’s not until we start seeing settlements that we get a kind of a better picture about how the government’s interpreting some of this [MDM guidelines],” he said.

Go Deeper Into the Allegations

The COVID-19 pandemic absolutely saw many justifiably high levels of MDM. “It was terrible, and we saw all extremes. We saw people die. I’m sure if they [the urgent care chain] were treating patients that were that severe they probably were billing level fives appropriately, assuming the documentation is right,” said Wolf.

The allegations: Evidence surrounding this case suggested the chief medical officer for the organization in question mandated that coders submit 99214/99204 (Office or other outpatient visit for the evaluation and management of an established/new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 30/45 minutes must be met or exceeded.) for any patient suspected of having COVID, regardless of symptoms or negative test. Coders were only to code lower than that level four when the patient had no symptoms and no known exposure to COVID.