Toccoa Clinic: Alleged Extra Visits and Inflated E/M Levels

In the Toccoa Clinic billing settlement, Toccoa Clinic Medical Associates and two dermatologists agreed collectively to pay $1.9 million to resolve allegations of extra Medicare visit charges on procedure days and upcoding of evaluation and management services. The government’s allegations raised separate questions: what additional service earned a payment, and what work supported the level billed? If you worked with the clinical notes or those claims, the difference matters. A review of the visit level can miss the more basic question of why the practice charged for an additional visit at all.

The U.S. Attorney’s Office for the Northern District of Georgia announced the civil settlement on April 18, 2016. That office and the Health and Human Services Office of Inspector General investigated the case. The allegations concerned the dermatologists’ billing, and the practice group joined them in the settlement.

The announcement placed the case in a national health care billing problem: the Health and Human Services inspector general had identified inappropriate E/M billing as costing taxpayers billions of dollars. We see why the extra visit charge deserves attention alongside the more familiar question of upcoding. Medicare can overpay because a level is inflated, but the alleged extra service puts another charge on the bill before the level even comes into it.

The Separate Service Behind the Extra Charge

The government alleged that the dermatologists billed Medicare for evaluation and management services alongside procedures when they had performed no significant, separately identifiable service. The added charge asserted that the encounter included care separately payable from the procedure.

That distinction is central to billing an extra visit on a procedure day. The U.S. Attorney’s Office announcement explained that providers could bill both services only when they performed a significant, separately identifiable E/M service. We see the problem in the alleged billing: the procedure brings the patient into the office, and the bill then claims additional care that the government says never happened. The additional payment needs additional work behind it.

For someone who knows the practice’s records, the useful comparison is the procedure documented and the E/M service charged for the same encounter. The clinical note explains the care, while the claim shows what Medicare was asked to pay. Reading them together puts the alleged extra service in view, before anyone debates how complex it was.

An Unsupported Visit Level Adds Another Payment Problem

The government also alleged that the dermatologists upcoded E/M services to higher levels than were appropriate, causing Medicare overpayments. More complex E/M services receive higher reimbursement. The allegation therefore concerned the amount claimed for the visit as well as whether a separate visit charge belonged on the bill.

Inflating the E/M level represents more work or complexity than the service supports. Lowering the level does not fix an extra charge for care that was never separately provided. Even when separate care occurred, the billed level still needs support. Toccoa’s two allegations make that sequence concrete: the existence of the added service and the price assigned to it need their own support.

The office-visit coding framework has changed since this settlement. Before 2021, levels generally depended on history, examination and medical decision making, with a narrower exception for counseling or coordination time. Under Medicare’s office-visit changes beginning January 1, 2021, levels use medical decision making or the practitioner’s qualifying time on the service date. We read recent claims against the rules in force on their dates and the care the clinician documented.

Skyline Urology and the Alleged Extra Visit

Skyline Urology agreed to pay $1,850,000 in 2019 over a similar Medicare billing allegation, close to the size of Toccoa’s collective settlement. In its Skyline settlement announcement, the Justice Department expressly alleged use of modifier 25 to bill routine E/M services separately when they were already included in same-day procedures. The modifier represented significant, separately identifiable work beyond the usual procedural care.

Skyline’s alleged additional visit charge put the existence of separate work at issue. Toccoa’s allegations also reached the level of E/M service billed. For a coder or clinician reviewing a procedure-day claim, those are different places where the bill can outrun the care.

What Evidence Does a Whistleblower Need?

For allegations like Toccoa’s, the useful evidence connects the procedure, the added E/M charge, the level billed and what people inside the practice knew. We examine the clinical record alongside the billing record, with the insider who can explain how the encounter became a claim. The treatment date, description of the work and signature give that account specific points of comparison.

The Journal of AHIMA article Busting Bad Medicine: A Call to Action Addressing Healthcare, Fraud, Waste, and Abuse, published in 2017, identifies upcoding and unbundling as examples of code misuse. It recommends examining the treatment date, treatment type and nurse or physician signature in the health record, then makes the point that gives an insider’s account its value:

That account can connect the care to the decisions behind the charge. You may know who required the extra E/M line, who selected a higher level or how management responded when someone questioned the billing. We examine those decisions with the claims they affected. An internal warning and the billing that followed it can explain something the final claim alone cannot: who knew about the discrepancy and what happened next.

The Recovery Behind a Whistleblower Reward

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. That reward comes from the recovery, and your knowledge of how claims were created can be central to pursuing it. For an E/M billing case, we work with you on both the care represented and the decisions behind the bills sent to Medicare.

You Know What the Visit Included

If your work puts you between the procedure note and the Medicare bill, talk with our whistleblower experts about the care behind those charges. We build the case with you and bring in physician billing whistleblower lawyers who understand separate E/M services and unsupported visit levels. From the first conversation through the pursuit of a recovery, we stay on your side of the table.