Ultimate Treatment Center: Take-Home Methadone Days and False Office-Visit Claims

The Ultimate Treatment Center / Ultimate Care Medical Services fraud case ended in an agreement by the clinic and its physician owner to pay $1.4 million over alleged false office visits, urine-test billing and prescribing violations. The government alleged that the clinic billed Medicare for office visits even on days when a patient took methadone at home. For someone who knows the dosing window, the patient charts or the billing system, the case turns on a familiar distinction: giving someone medication and providing the professional service on the claim.

Ultimate Care Medical Services, LLC did business as Ultimate Treatment Center in Ashland, Kentucky. The Justice Department announced the civil settlement on August 16, 2019. It resolved allegations under the False Claims Act and the Controlled Substances Act against both the clinic and its owner. The government alleged that the owner directed the billing.

A Methadone Dose Billed as an Office Visit

The government alleged that Ultimate Treatment Center billed Medicare and Kentucky Medicaid for evaluation and management services that it did not provide between January 2013 and September 2014. The government’s complaint describes the dosing routine: a patient checked in, approached a window, had their identity and dose verified, took the methadone under a nurse’s observation, and left.

According to the complaint, the nurse did not take or review a medical history, perform an examination, take vital signs or make decisions about the patient’s diagnosis or future treatment. The patient would not typically see a physician or another practitioner for an examination, counseling or other treatment during that visit. Yet the clinic allegedly submitted an evaluation-and-management claim for the encounter.

The complaint put the pace at 250 to 300 patients receiving doses during an eight-hour period, with nurses spending less than two minutes per patient on average. It alleged that the clinic generally used CPT code 99212, an established-patient office-visit code. The complaint described that code’s requirements at the time as including at least two of three components: a focused history, a focused examination and straightforward medical decision-making.

According to the complaint, nurses recorded the medication dose. The claim represented clinical work that the government said had never happened.

The Billing Instruction Came Before the Note

The complaint alleged that the clinic’s owner chose the billing approach after receiving the code definitions. In January 2013, the billing company sent her written definitions of evaluation-and-management codes and asked which code to use for daily methadone administration. Her alleged response:

The clinic “will put a note everyday,” she allegedly told the biller. We see the problem in that order of operations: find the code an insurer will pay, then supply the note to support it. The billing company’s question and the owner’s alleged answer connect the claims to a decision inside the business.

According to the complaint, the clinic’s electronic medical record system allowed practitioners to clone notes. The government alleged that copied histories, observations and treatment plans created the appearance of daily professional evaluations. Those records continued for days, weeks and months with nearly identical content.

The people who actually administered the medication allegedly did not create those clinical notes. The dosing nurses used Methasoft, which automatically recorded the date, time and dose in a dosing log. That separation matters to an insider: the log recorded the encounter at the window, while another record purported to describe the professional work supporting payment.

Take-Home Methadone Days Became Billed Visits

The complaint alleged that Ultimate Treatment Center created office-visit records and billed Medicare on dates when a patient was absent from the clinic. Its example followed a patient who received a dose at the clinic on January 20, 2014, together with two doses to take at home on January 21 and 22.

According to the complaint, the clinic created the same cloned records for those take-home dates as it did for clinic dosing dates and submitted evaluation-and-management claims to Medicare. The government alleged that this happened on numerous dates. The medication went home. The office visits appeared on paper. In the government’s account, Medicare was paying for professional care the patient never received.

The complaint alleged that the cloned notes warned of a high risk of diversion if the patient took methadone at home, even as the clinic supplied the take-home doses. The note warned against the very arrangement the clinic had made.

The complaint also described what happened after that patient’s urine screen showed a positive opiate result on April 24, 2014. Later notes allegedly repeated the earlier language without acknowledging the result, documenting a discussion with the patient or recommending a change in dosage or therapy.

For an employee familiar with those records, the question is who wrote the account of care and what work that account actually described.

Urine Tests the Equipment Could Not Perform

The government separately alleged that Ultimate Treatment Center billed Medicare and Kentucky Medicaid for complex urine drug tests that its equipment could not perform, from July 2013 through December 2014.

A qualitative test reports whether a substance is present or absent. A semi-quantitative test reports a range for its concentration. A quantitative test reports a specific numerical concentration. The government described quantitative testing as generally reimbursed at a higher rate.

According to the complaint, the clinic used a Cobas Integra 400 analyzer that produced qualitative and semi-quantitative results. Its patient records reported those types of results. The clinic nevertheless allegedly billed using codes for quantitative drug tests, including two units of CPT code 83925 for opiates per patient encounter. The complaint contrasted those claims with qualitative testing codes such as G0434 for moderate-complexity tests during that period.

Here the government’s account connects the equipment, the reported result and the claim. A lab worker may recognize the analyzer’s output. A biller may recognize the test code. We bring those views together to establish how the test performed compares with the test charged to the government.

The Buprenorphine Patient Limit Was a Historical Rule

The prescribing allegation concerned the physician owner’s patient limit in 2014. The government said her authorization allowed her to treat 100 patients with buprenorphine, but that she exceeded the limit during a three-month period. The complaint alleged that she issued prescriptions for 294 unique patients in September 2014.

That limit has since been removed. Congress eliminated the separate buprenorphine waiver and its patient caps on December 29, 2022, a change the Drug Enforcement Administration explained in its January 2023 letter to registered practitioners.

The Payment Model Defines What the Claim Represents

A medication dose, a separately billed office visit and a treatment bundle each describe a different unit of care.

Medicare’s opioid treatment program uses a weekly payment model that covers seven consecutive days, with at least one drug or nondrug service required during the week. Ultimate’s alleged evaluation-and-management claims represented individual professional encounters.

A related distinction appears in the government’s 2023 complaint against Journey to Hope Health and Healing. The government alleged that its Rhode Island Medicaid methadone-treatment claims represented a bundle with required individualized treatment plans and counseling, while some patients received medication without that accompanying care. It also alleged that management directed employees to create and backdate documents before audits.

The shared pattern is a difference between the treatment delivered and the treatment described for payment.

What Evidence Is Needed to Prove Fraud?

The government’s complaint connected dosing logs and patient presence to the clinical notes, billed services and decisions behind them. It made those connections through specific take-home dates, the owner’s response to the billing company, copied records and the testing equipment’s output.

The investigation involved the Drug Enforcement Administration, the Federal Bureau of Investigation and the Kentucky Attorney General’s Medicaid Fraud and Abuse Control Unit. The United States brought the civil case against the clinic and its owner.

If you recognize a similar healthcare billing pattern, your knowledge of how the clinic worked can explain a discrepancy that a claim alone leaves unanswered. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

You Know What Happened at the Dosing Window

If the notes describe visits you know never happened, speak with our whistleblower experts about those claims. We turn your knowledge of the dosing window and billing system into the foundation for your strongest health care whistleblower case, find healthcare fraud whistleblower lawyers who know treatment billing, and stay beside you through the case.