Aptihealth: Billing No-Shows and Counting Messages

The Aptihealth fraud settlement required the company to pay $300,000 over Medicare and Medicaid billing that included no-show appointments and patient messages billed without regard to clinical content. Aptihealth admitted responsibility for the conduct. For someone who handled scheduling, answered messages or reviewed claims, the case reaches into familiar work: whether the appointment happened, what the response actually said, and what the company billed for it.

Aptihealth provides behavioral health services through its own telehealth platform from Clifton Park, New York. Its services include diagnostic interviews, therapy and medical management. The settlement covers Aptihealth Inc. and Aptihealth Medical, PLLC, formerly Professional Medical Concierge Services, PLLC.

A former employee brought the qui tam case under the False Claims Act, and the United States joined it for settlement. The Justice Department announced the resolution on June 23, 2026. The United States Attorney’s Office for the Northern District of New York investigated the matter jointly with the New York Attorney General’s Medicaid Fraud Control Unit.

What Aptihealth Admitted

Aptihealth accepted responsibility for five categories of conduct in the signed settlement agreement. The covered period ran from January 1, 2020 through December 31, 2023:

1. No-show appointments. The company billed Medicare and Medicaid for appointments that did not occur because the patient did not attend.
2. Patient messages. Staff responses generated claims without regard to whether the exchange involved billable patient care or administrative matters. Billing followed the number of messages rather than their clinical content.
3. Psychological testing. Some claims lacked sufficient documentation for the testing evaluation services billed.
4. Patient incentives. The company operated a gift-card program tied to therapy attendance.
5. Compliance controls. Its program failed to meet New York requirements concerning inaccurate billing, monitoring and training.

That last admission matters as much as the individual billing categories. The agreement reaches both the claims and the system meant to catch what was wrong with them.

Why No-Show Billing and Message Billing Are Different

A no-show claim represented an appointment that never occurred. Aptihealth’s message claims concerned responses that staff actually made, but billed without regard to whether their content supported the service charged.

Remote care takes several forms. A scheduled video visit involves a patient and practitioner communicating in real time. A patient-portal e-visit involves a patient-initiated exchange with an established practice. A virtual check-in is a brief communication to assess the patient’s needs. These are separate service categories in Medicare’s telemedicine guidance. The distinction gives the billing staff a substantive question: what care did this exchange contain?

The Aptihealth agreement names CPT codes 98966, 98967, 98968, 98970, 98971 and 98972 for time-based telephone and portal assessment and management of patient health.

The company accepted responsibility for this description:

An administrative reply had become a claim for patient care, billed to Medicare and Medicaid at taxpayers’ expense. The distinction sat in the message itself, where the person answering it could see it.

What Evidence Is Needed to Prove Fraud?

In a case like Aptihealth’s, the evidence connects the appointment, message or testing work to the service represented on the claim. Scheduling staff, message-triage staff, clinicians and billing reviewers can each know a different part of that connection.

For a missed appointment, the useful comparison is between the appointment history, the platform’s record of patient contact and the submitted claim. For a message exchange, it is between the thread’s clinical content, who responded and the service billed. Our whistleblower experts work with the insider to understand how those records fit together and where the billing decision was made.

The testing admission requires a different comparison. CPT code 96130 covers the first hour of psychological testing evaluation, including interpreting test results and clinical data. Aptihealth admitted that a portion of its claims under that code covered services that were insufficiently documented.

The testing file therefore matters for what it says about the evaluation work. The agreement puts the documentation failure beside the no-show and message admissions because each exposes a different gap between the service represented and its support.

Platform operations also explain why one employee may see only part of the problem. Scheduling and billing are administrative functions, while the treating professional supplies the clinical assessment and medical record. A platform supplies the communication and workflow records. An insider who understands how those pieces meet can explain a claim in a way its billing code alone cannot.

What the Aptihealth Agreement Requires

The federal agreement allocates $183,297 to the United States and $116,703 to New York, with the state’s payment governed by a separate agreement.

The agreement also requires a separate $55,000 payment for the whistleblower’s attorneys’ fees, costs and expenses. The whistleblower’s share of the government’s recovery has its own provision.

Gift Cards and the Controls That Failed

Aptihealth’s patient incentive tied a benefit to attending therapy. The agreement describes a program for approximately 15 patients, with a $25 gift card after at least one therapy session. Aptihealth represented that it distributed no more than $250 in total gift cards and ended the program by December 31, 2021.

The Justice Department said the United States contended that the arrangement violated the Anti-Kickback Statute. The admitted operational fact is the link between the gift card and attendance.

The compliance admission names the work the controls were supposed to perform: detecting inaccurate billings, routinely monitoring and identifying compliance risks, and ensuring adequate training and education. Those functions connect directly to the conduct in the agreement. A review of message content addresses what counting messages misses. A review of testing documentation addresses whether the evaluation claim has support.

When Volume Becomes the Reason for a Bill

Another telehealth case shows how a recurring volume target can displace the patient’s need for care. In its April 2022 settlement announcement concerning Physician Partners of America, the Justice Department alleged that the company scheduled telemedicine visits every two weeks regardless of patient need after Florida paused non-emergency procedures. The increased visits were allegedly intended to replace lost procedure revenue. The case also included allegations of medically unnecessary testing.

That alleged scheduling rule and Aptihealth’s admitted message-count billing expose a common problem: volume taking the place of a clinical reason for the claim. The relevant business decision may be visible to the employee arranging the appointments or processing the messages, well before anyone outside the company examines the bill.

Can You Get Paid for Reporting Medicaid Fraud?

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

The whistleblower who brought the Aptihealth patient-message and no-show case was a former employee. The federal settlement sets that whistleblower’s share at 17% of each federal settlement payment the United States receives.

The employee’s role is the useful point for someone inside another healthcare business. Scheduling, message handling, testing documentation and billing oversight are all places where an insider may understand how the claimed service diverged from the work. We work with that knowledge to build the case around the actual health care claims.

You Know What Was Behind the Claim

If you saw missed appointments or administrative messages become claims for patient care, speak to one of our whistleblower experts about what was billed. We build your case around the connection between the work, the bill and the company’s decisions, and bring in healthcare whistleblower lawyers who understand telehealth billing. We stay alongside you through the case, drawing on what you know about how appointments and messages became bills.