Visiting Physicians Association: Four Whistleblowers Behind the House Calls

In the Visiting Physicians Association fraud settlement, the practice agreed to pay $9.5 million to resolve allegations of unnecessary home visits, care-plan oversight, tests and procedures, and inflated evaluation and management claims. For a clinician, care coordinator or biller who knows the work behind a home visit, the case puts the clinical need and the billed service side by side.

The Justice Department announced the agreement on December 23, 2009. It resolved allegations involving Medicare, TRICARE and Michigan Medicaid, with payment to the United States and Michigan. Visiting Physicians Association was a Michigan professional corporation based in Farmington Hills that had provided home health care services at various times in Michigan, Ohio, Georgia and Wisconsin.

What Are Some Examples of Fraud in Medical Practice?

The Visiting Physicians Association allegations covered unnecessary services and visit claims that overstated the complexity of the care delivered. The government identified distinct problems within that account:

• Unnecessary home visits. The government alleged that the practice billed public programs for visits patients did not need.
• Unnecessary care-plan oversight. The government challenged whether the oversight service billed was needed.
• Unnecessary tests and procedures. The government challenged the clinical need for these services as well as for the home visits.
• Inflated evaluation and management services. The practice allegedly billed for more complex services than it actually provided, the mismatch at the heart of physician upcoding.

Those allegations ask different questions of someone inside a practice. A clinician may know why a visit or test was ordered. A coder may know whether the billed level describes the encounter. We see two ways taxpayers can be overcharged in these allegations: unnecessary care and an inflated bill for the work delivered.

The Physician Service Behind the House Call

Visiting Physicians Association’s settlement concerned professional physician services delivered at home. The 2011 textbook Health Care Administration: Managing Organized Delivery Systems, published by Jones and Bartlett Publishers, describes evaluation and management coding as a way to measure the complexity and intensity of a visit. In this case, the government alleged that the practice claimed more complex services than its clinicians delivered.

Care-plan oversight deserves its own attention because the government’s allegation concerned unnecessary oversight services. In today’s chronic care management billing, the worker’s identity, actual work, care planning and time are central to the service claimed. For an insider, the connection between care planning and the claim runs through the person who did the work and the record of that work.

Four Whistleblower Suits Behind the Settlement

Four whistleblowers. One practice. The private plaintiffs brought qui tam cases under the False Claims Act, and the settlement resolved all four lawsuits. A qui tam case lets a private party bring a case on the government’s behalf and share in what it recovers. The U.S. Department of Health and Human Services, Office of Inspector General, the FBI and the Michigan Attorney General’s Office investigated the matter.

How Much of a Settlement Does a Whistleblower Get?

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. In Visiting Physicians Association’s case, the agreement provided for approximately $1.7 million collectively for the four whistleblowers. The agreement provided for that combined whistleblower reward as their share of the settlement recovery.

What Evidence Does a Whistleblower Need?

For allegations like these, useful evidence connects the claim to the patient’s clinical need, the service delivered and the person who did the work. We examine the healthcare billing records with the insider who understands how the practice produced them.

The Journal of AHIMA article Busting Bad Medicine: A Call to Action Addressing Healthcare, Fraud, Waste, and Abuse, published in 2017, recommends checking treatment dates, treatment types and nurse or physician signatures in the health record. It then makes the point that matters to the person who was there:

For home-visit billing, that comparison reaches across the workday. We connect the visit note and billed service with schedules, travel records and the actual clinician.

For a test or procedure, we examine the order, clinical reason, result and how the result was used. That reason may sit in symptoms, measurements or an earlier test result. We compare those records with the reason given for the next service, because the need for care is central to these allegations. For care-plan work, we ask what activity the record describes and who can explain it.

The compliance-program chapter in Health Care Administration describes how physicians narrowing an audit or changing its findings can compromise the review. For an employee who saw a billing review narrowed or its findings rewritten, what happened to the review may help explain why the billing continued.

Another Practice, the Same Gap Between the Visit and the Bill

Toccoa Clinic and two physicians reached a separate settlement over allegations that they billed evaluation and management services on procedure days without a significant, separately identifiable visit and billed visit levels higher than the work supported. The Justice Department’s settlement announcement described both allegations. The parallel is the distance between the service claimed and the encounter the clinical record describes.

An insider may see that distance from either side of the bill. The treating clinician knows the work performed, while the coding or billing employee sees the service sent to the payer. Our work brings those accounts together around the government payment they explain.

You Know What Happened During the Visit

If you know why home visits were ordered, how care-plan work was recorded or why the billed level changed, speak to one of our Whistleblower Experts about the home visits you saw billed. We connect your knowledge of the practice to the claims, bring in physician billing fraud whistleblower lawyers and stay beside you to build your strongest home visit billing case.