Alabama Physician Files Duplicate Claims for Maximum Reimbursement

A $1.4 million settlement ended a year-long suit which alleged that an Alabama physician repeatedly filed false claims to Medicaid, Medicare, and TRICARE, often for procedures that were medically unnecessary. James Crumb, the Mobile-based practitioner who specialized in Mobility Metabolism and Wellness, was found to have filed up to thirty identical false claims for a singular patient visit – a practice that required deliberate manipulation of billing codes in order to dupe the initiative put in place to prevent just that.

The National Correct Coding Initiative (NCCI) was designed with the intention to prevent fraudulent or unnecessary claims from being processed simply by analyzing the codes that are submitted by facilities seeking reimbursement. The program detects a number of “red flags” that indicate a claim is not eligible for payment, including when multiple claims are filed for the same procedure; this methodology was apparently well-known by the staff at the facility in question, as they purposefully miscoded procedures as “ultrasound guidance” claims, which are an exception to this rule, in order to file duplicates and receive maximum potential reimbursement.

Although they filed these claims as such, the true nature of the treatments performed were far from medically necessary – among the most absurd, Botox injections. Knowing these would not be reimbursed by government-funded healthcare of any kind, the physician in question would certify that the patients had rare neurological diseases that could only be treated with “trigger point injections,” then manipulating the records to reflect the false diagnoses in order to bilk the programs.

Once establishing that he was able to bypass the NCCI safeguards, Crumb continued on to forge documents outlining the amount of Botox his patients required and consequently received extravagant amounts of the drug. Once the Alabama Medicaid Agency approved and paid for these inflated doses, it was discovered that Crumb did not actually administer them to the patients to which they were prescribed.

In his settlement, Crumb consented to take part in a Corporate Integrity Agreement, during which the Office of the Inspector General is permitted to regularly audit and observe his practices to ensure he is compliant with all federal healthcare regulations. In addition, he is bound into a three-year contract that requires all claims submitted by his practice undergo independent review.

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