Associates in Dermatology: Radiation Work by an Unlicensed Assistant

In the Associates in Dermatology settlement, the Central Florida practice and its physician owner agreed to pay $3 million to resolve allegations of improperly supervised radiation therapy and unnecessary skin-lesion procedures. The allegations covered January 1, 2009 through October 2013, reaching both the treatment room and the bills sent to the government.

The Justice Department announced the settlement on January 23, 2015. Three former employees brought the case, challenging who performed the services, who supervised them, whether patients needed them and what the clinic documented. An employee in the treatment room can see what a billing entry leaves out.

Radiation Therapy by an Unlicensed Medical Assistant

The government alleged that the physician owner operated a practice where an unlicensed medical assistant performed radiation therapy without proper supervision. The whistleblowers also alleged that, in many instances, the assistant lacked the basic knowledge needed to perform the tests she was performing. The release described claims for procedures performed by unlicensed, uncredentialed and unsupervised employees. For an employee who saw the treatments, the question reaches beyond a billing entry to the qualifications and supervision behind it.

The Skin-Lesion Allegations Concerned Necessity and Documentation

The settlement also resolved allegations that Associates in Dermatology performed unnecessary destructions of skin lesions and lacked proper documentation for those procedures. These allegations concerned why treatment was performed and what supported the bill. They were separate from the radiation assistant’s qualifications and supervision.

The distinction matters to someone who knows only one part of the practice. A clinician may know the reason for treating a lesion. A biller may know what the chart said when the claim went out. Connecting those accounts is how we examine a suspected medical necessity fraud case without losing the clinical facts inside a discussion of billing codes.

We take the alleged lack of documentation seriously because the chart is supposed to explain the care the government is being asked to pay for. The allegation here also reached the treatment itself: the whistleblowers said the clinic performed unnecessary procedures on patients. A signature can identify who stands behind a chart entry, but it cannot supply a clinical reason for a procedure the patient did not need.

What Evidence Does a Whistleblower Need?

We help a whistleblower connect what happened in the treatment room with the treatment record and the claim. The useful evidence of physician billing fraud may be a mismatch among the actual performer, credentials, supervision, documented treatment and billed service. We examine those connections with the person who understands how the practice worked.

The Journal of AHIMA’s 2017 article Busting Bad Medicine: A Call to Action Addressing Healthcare, Fraud, Waste, and Abuse explains why the employee’s account matters alongside the chart. It identifies treatment dates, the type of treatment and clinical signatures as useful documentation, then makes the point that paperwork alone cannot supply the whole account:

That is why we want to hear what you saw as well as what the records say. A person familiar with the daily work can explain a discrepancy that a signature, schedule or billing entry leaves unexplained. An appointment schedule may place a patient at the clinic, while the treatment record describes the service and the claim asks for payment. Your knowledge of who actually did the work gives those entries context. We bring that account into the case, rather than treating the chart as the whole story.

Former Employees Brought the Case

Three former clinic employees filed the False Claims Act qui tam case that led to the settlement. They alleged that the practice and its owner knowingly submitted false claims to the government for payment.

The FBI and the Health and Human Services Office of Inspector General were among the agencies that investigated. Federal prosecutors in the Middle District of Florida handled the matter.

The announcement singled out Medicare and TRICARE among the federal health care programs the government sought to protect. The Health and Human Services Office of Inspector General also pointed directly to the importance of documenting services billed to Medicare. For the employee who knows the patient encounter, that connects the clinic’s records to the public money paying for care.

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. The Justice Department announced that the former employees in this case would receive a whistleblower reward from the settlement.

Another Dermatology Radiation Settlement

Dermatology Healthcare was part of a separate $4 million settlement announced on August 28, 2018, involving allegations of inadequately supervised superficial radiation therapy, upcoded related procedures and overused simulations. Both cases put the supervision behind a radiation bill at the center of a False Claims Act settlement.

The Dermatology Healthcare allegations concerned treatment for nonmelanoma skin cancer. They also reached how the practice described related procedures on claims and how often it used simulations. That gives an insider another part of the pattern to recognize: the alleged problem can involve both the people delivering treatment and the services billed around it. Someone who understands the treatment may see a problem with supervision, while someone handling claims may see the way the practice described or counted its work. We want to hear either account.

You Know Who Performed the Treatment

If you worked in a dermatology practice and saw radiation services or lesion procedures billed differently from the care delivered, tell our whistleblower experts what happened. We work beside you to build your strongest health care whistleblower case around what you saw in the treatment room or billing office, and bring in health care fraud whistleblower lawyers who understand practice billing. You bring the view from inside the clinic, and we bring the expertise and partnership to pursue it with you.