Medicare Compliance & Reimbursement

Prescription fraud, E/M upcoding, and more factor in latest settlements.

You might have noticed that the feds seem to be ramping up their midyear fraud enforcement activity. In fact, June was a particularly busy month with more than 35 civil and criminal actions, including many cases with million dollar price tags and significant prison terms. Read on for the scoop.

Beware of E/M Upcoding Issues

One practice learned the hard way that submitting higher-level evaluation and management (E/M) codes that don’t support the level of service will land you in hot water. On June 5, Bluestone Physician Services of Florida LLC, Bluestone Physician Services, P.A. and Bluestone National LLC, which operate in Florida, Minnesota and Wisconsin, agreed to pay more than $14.9 million to resolve False Claims Act (FCA) violations.

“The settlement resolves allegations that, during the period from Jan. 1, 2015, through Dec. 31, 2019, Bluestone knowingly submitted claims for two E&M codes, the domiciliary rest home visit code for established patients (99337) and the chronic care management code (99490), that did not support the level of service provided,” a Department of Justice (DOJ) release says. Bluestone submitted the upcoded E/M claims to Medicare, Medicaid, and Tricare for chronic care patients in both assisted living and at other facilities.

The settlement is part of a qui tam case brought by the general manager, who will receive more than $2.8 million under the resolution. The federal government’s share of the settlement consists of more than $13.8 million while Florida and Minnesota will receive about $1.1 million, the DOJ notes.

Other high profile cases include:

Mental health: Boston psychiatrist Gustavo Kinrys billed Medicare and other payers more than $19 million for treatments he never provided, and then he attempted to conceal his crimes from the feds.

Between January 2015 and December 2018, Kinrys billed Medicare and others “for thousands of TMS sessions he never provided, including over 8,000 sessions he claimed were provided to 74 patients,” the DOJ notes in a release. During his numerous vacations both in and outside the U.S., he billed payers “for millions of dollars’ worth of psychotherapy sessions he never provided, including over 900 face-to-face sessions,” and more than “24 hours’ worth of psychotherapy services in a single day, including one day in July 2017 when he claimed he had provided hour-long psychotherapy sessions to 70 different patients,” the DOJ continued.

Last October, “Kinrys was convicted of seven counts of wire fraud, six counts of false statements relating to health care matters, and one count of obstructing a criminal health care investigation,” the DOJ says. On June 7, Kinrys was sentenced to more than 8 years in prison, ordered to pay restitution, and a future forfeiture of funds will be determined at a later date.

Orthotics: Portland, Maine-based physician Jamie Loggins settled FCA allegations after billing Medicare for orthotic braces that weren’t medically necessary — and for beneficiaries he had no prescriber-patient relationship with. From September 2018 through November 2022, claims were submitted to Medicare that were not medically necessary as part of a telemedicine consultation scheme he was a part of.

“Loggins would review prepared intake forms, which included purported complaint information for a beneficiary and prepared prescriptions for orthotic braces. Frequently, the intake forms included multiple complaints and prescriptions for orthotic braces for each individual beneficiary,” DOJ says in a release. “The Government alleges that Dr. Loggins would then electronically sign these prescriptions, despite there being no valid prescriber-patient relationship and no medical necessity for the claims,” the agency adds.

Loggins agreed to pay the feds more than $629,000 to settle the allegations.

Sleep studies: The government filed a lawsuit against neurologist and pain management physician Mustafa A. Hammad from Panama City, Fla. after he submitted claims to Medicare and Medicaid for 582 sleep studies performed while he was outside of the U.S. — a direct violation of the FCA. Hammad “entered into a consent judgment and settlement agreement to resolve a pending lawsuit filed by the United States pursuant to the False Claims Act and the Controlled Substances Act,” the DOJ says in release.

Additionally, the U.S. asserts that Hammad issued prescriptions and approximately 4,787 additional services while abroad, which are also violations of the CSA and FCA respectively.

He has agreed to pay $550,000 to resolve the allegations and lawsuit, DOJ says.