We have discussed a variety of ways that healthcare providers may try to bend the rules to obtain more money from programs such as Medicare and Medicaid. Upcoding is a common issue in healthcare fraud. This occurs when the provider uses the billing code assigned to a more expensive procedure or service than was actually provided. Charging the government for services that were never provided is also common. An interesting twist that seems to fall somewhere between these two common kings of healthcare fraud schemes arose in a recent whistleblower lawsuit on the East Coast.
No Supervising Physician, Despite Medicare Rules
An employee of an MRI provider says the imaging company was performing contrast MRI scans of patients, according to the lawsuit. Dye is injected into the patient in these procedures to enhance the contrast in the final images, making it easier to observe certain types of tissue. However, the worker says that he noticed there was no medical doctor personally supervising the procedure. Medicare rules require these procedures to be personally supervised by a physician. Obviously, the physician’s fees are built in to the billing code.
The worker asked the owner of the MRI facility who was supervising the contrast MRI scans, according to the court records. The owner allegedly told the worker that the supervising physician was a doctor who had the office next-door to the MRI facility. The lawsuit indicates that the doctor was not even aware the he was being listed as the supervising physician. The records state that the doctor was never present during the procedures. The federal government tried to subpoena the facilities doctor resource records. The documents were void of any record of a physician supervising the contrast MRI scans.
The scheme does not really include upcoding per se, as there is no suggestion that the wrong code was presented to Medicare. However, the execution of the procedure did not follow the rules. The scheme essentially obtained reimbursements for services that were never provided.
Whistleblowers Participate In Any Recovery
Whistleblowers are entitled to receive a percentage of any judgment or settlement that results from a whistleblower lawsuit. In this case, a recent news reports says whistleblower who initiated the lawsuit will receive roughly 18 percent of the proceeds. That translates to about $2.9 million.
The case was resolved through a default judgment. The owner of the imaging facility and the company took no action to defend against the allegations in court.