American Pain Management: False Office Claims Behind the Prescriptions

American Pain Management’s owner admitted approximately $1.2 million in false Medicare pain-management service claims and acknowledged knowing about prescriptions without visits or a legitimate medical purpose. His criminal guilty plea connects the prescription to the office bill: the owner knew how the prescriptions were being issued, and Medicare received false claims for professional care. Someone inside the clinic could recognize the difference between a prescription leaving the office and a patient receiving the care on the bill.

The Justice Department’s June 13, 2019 account reported the owner’s conspiracy plea. A separate criminal information charging the receptionist and office manager described common ownership of American Pain Management’s clinics in Tamarac and West Palm Beach and Pacific Pharmacy in Miami.

The Office Claims and the Pharmacy Claims

The Justice Department’s account of the owner’s case separately described more than $1 million in pharmacy claims. That money concerned Pacific Pharmacy’s billing, while the professional-service claims concerned care billed through American Pain Management.

The criminal information against the office manager explains the payment arrangements behind that distinction. Medicare Part B covered physician and clinic services. Part D subsidized prescription drugs through private drug plans, with pharmacies submitting claims to a plan or its pharmacy benefit manager.

For an employee, that separation gives the prescription different significance on each side of the business. At the clinic, the treatment record should explain the professional care claimed. At the pharmacy, the prescription connects to the medication dispensed and billed.

What the Owner Knew About the Prescriptions

The owner’s knowledge puts the business operator inside the billing story. We see the abuse plainly: the person running the business knew the medical premise behind its Medicare claims was missing. A signature was standing in for care.

That is why an insider’s account of office operations matters alongside the clinical record. A person familiar with appointments may know whether a visit occurred. A person handling prescriptions may know how they reached the physician for signature. A billing employee may know what service the practice then claimed. We connect those accounts to understand who knew the difference between the care and the bill.

What the Office Manager Was Charged With

The criminal information charged the receptionist and office manager with conspiring with the owner and others to submit false claims through American Pain Management and Pacific Pharmacy. The information alleged claims for physician services and prescription medications that were not medically necessary or eligible for reimbursement. It placed the alleged conspiracy from around January 2009 through around April 2018, connecting front-office operations, prescribing and pharmacy billing.

The information also alleged that the participants caused excessive and inappropriate quantities and combinations of controlled substances to be prescribed and dispensed. It alleged that they added excessive quantities of non-controlled medications to disguise the controlled-substance quantities. That allegation gives the medication list a business purpose beyond treatment: other drugs allegedly helped obscure what the operation was dispensing.

The same filing alleged that the participants dispensed expired medications that were ineligible for reimbursement. For someone working with pharmacy inventory or claims, the condition of the drug supplied becomes part of the government-payment question. These allegations concern what reached the patient as well as what reached the payer.

What Evidence Does a Whistleblower Need?

For false pain-service claims, useful evidence connects the prescription, the patient encounter and the submitted bill. The criminal information describes claims identifying the patient, service, billing code, service date and referring provider. It also describes the provider’s certification that the services were medically necessary and actually provided as billed. Those are concrete representations an employee’s knowledge can illuminate.

The clinic’s treatment record and the submitted claim tell different parts of the same transaction. The record describes the assessment and care, while the claim asks for payment for a particular service. Medicare’s medical-record guidance requires support for the work, medical necessity and signatures. A signature cannot create care that never occurred.

The Journal of AHIMA’s 2017 article, Busting Bad Medicine: a Call to Action Addressing Healthcare, Fraud, Waste, and Abuse, recommends comparing the treatment date, treatment details and nurse or physician signature. Its explanation reaches the part an insider supplies:

In a case involving prescriptions without visits, the person who understands the schedule or prescription workflow can explain what an entry leaves out. We examine that account alongside the service claimed and the payment sought. The employee’s value is knowing how the transaction actually happened.

Physician Involvement on the Bill

In its guilty plea, Pain Specialists admitted billing under its physician owner’s National Provider Identifier while he traveled, for services requiring his personal consultation or direct supervision. The Justice Department’s account of that corporate plea describes a different way the physician’s identity could remain on a claim when the required involvement was missing. An employee who knew the physician’s whereabouts could explain something the billing number concealed.

In each case, someone inside the practice could understand the physician’s involvement differently from the payer reading the bill. That connection also runs through pain-clinic billing tied to access to prescriptions, where the question is what care the practice made the prescription generate and then billed to the government.

The Government Claim Behind the Prescription

If you know the practice billed Medicare for visits that never happened, we want to hear what you saw. We assess that connection with you, including what you know about prescriptions, office services and the business decisions behind them. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

You Know What Happened Before the Prescription

If you handled the appointments, prescriptions or billing and know the care did not match the claim, speak to one of our Whistleblower Experts about the false bills. We build the case with you around that knowledge and bring in physician billing fraud whistleblower lawyers who understand how clinic services and pharmacy claims connect. You have a partner from the first conversation through the pursuit of the government’s recovery.