Large Oncology Practice Pays $4.1 Million False Claims Settlement

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Original story posted on: September 21, 2012

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Georgia Cancer Specialists, a 27-office oncology practice in the Atlanta area, will pay $4.1 million to settle claims that it billed evaluation and management (E/M) services on the same day as related procedures.

Medicare generally doesn’t pay for E/M services on the same day as related procedures, though it allows providers to append modifier 25 to claims in the limited cases where such a payment would be permissible, according to the U.S. Attorney’s Office in northern Georgia. However, Georgia Cancer Specialists affixed the modifier to claims inappropriately, leading to overpayments.

Providers should be aware of the potential for abuse of modifier 25; the Office of Inspector General (OIG) lists that topic in its yearly work plans because of “widespread abuse” of the modifier, the U.S. Attorney’s Office states.

In other fraud news:

  • The owner of A Caring Hand Home Health Care Services in Norfolk, Va., pleaded guilty Sept. 18 to health care fraud, alteration of records and aggravated identity theft. Janice Holland of Suffolk, Va., filed almost 940 false and fraudulent claims with Virginia Medicaid that indicated her company had provided respite care to 30 Medicaid recipients, though no care was provided, according to the U.S. Attorney’s office in eastern Virginia. She also used patients’ protected health information without authorization to bill the claims between January 2008 and October 2011. Her payments totaled $630,000.
  • More than 50 people were victims of Jo Benoit, aka Elissa Jo Benoit, who posed as a psychiatrist and prescribed medications for patients with bipolar disorder, post-traumatic stress disorder and other serious mental health conditions, according to the U.S. Attorney’s Office in eastern Pennsylvania. Benoit stole the identities of legitimate psychiatrists and forged prescriptions in their names, the U.S. Attorney’s Office stated. She used one psychiatrist’s identity to bill insurance companies more than $500,000 for patient visits, the U.S. Attorney’s Office stated. She was sentenced to six years in prison.
  • A southern Illinois doctor that had fled to Peru after defrauding insurance companies of more than $400,000 in the 1990s has been extradited and pleaded guilty to health care fraud, mail fraud and failure to appear, according to the U.S. Attorney’s Office in southern Illinois. Dr. Juan Rios submitted false claims for medical treatment and services that were not provided and also fraudulently received more than $250,000 in personal disability payments, the U.S. Attorney’s Office stated. Sentencing will be Jan. 4.

RACs Post Two Issues

Recovery auditor (RAC) Performant Recovery posted one issue for seven states in its region about incorrect units of Adenosine. Region C RAC Connolly posted a new complex physician issue to review incorrect billing of evaluation and management (E/M) claims.

Outpatient hospital

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Adenosine 6 mg – incorrect units reported

9/14/12

Conn., D.C., Del., Md., N.J., N.Y., Pa.

Identified overpayment of Adenosine 6 mg when reported with units greater than five.

FDA-approved Adenocard package insert, Astellas Pharm US Inc.; CMS-approved Pharmaceutical Compendium Thomson Micromedex Drug DEX, Adenosine; CMS Pub. 100-02 chapter 10

Physician

Name of issue

Date posted or approved

Regions/states where it is active

Description of issue

Document sources

Incorrect billing of evaluation and management claims

9/12/12

RAC Region C

Limited review – Statistical sampling on evaluation and management claims to calculate and project incorrectly paid claims.

CMS Pub. 100-08, change request 3734

About the Author

KarenLong is the editor of Physician Solutionsfor DecisionHealth and oversees products that relate to fraud and abuse and HIPAA compliance for physician offices and home health agencies, and accreditation compliance for hospitals. In her almost four years at DecisionHealth, Karen also has been the compliance editor and a reporter for Home Health Line, nation's leading independent authority on home healthcare business, regulation and reimbursement.

Contact the Author

KLong@decisionhealth.com

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Karen Long

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