Central New York Physician Medicaid Fraud Settlement: Alleged Upcoding and Poorly Documented Smoking Counseling

A Central New York physician and his practice agreed to pay $568,750 to the state to settle Medicaid fraud allegations of upcoded medical services and insufficiently documented smoking-cessation counseling. The allegations turn on a comparison a clinician or biller can recognize: what the practice charged for against what the care and its records supported. A higher bill does not put more care into the visit.

The New York Attorney General announced the settlement on October 24, 2022. The physician was the principal owner of a general medical practice with offices in Groton and Tully. The resolution involved the physician and his professional corporation, with a companion federal civil agreement addressing the billing allegations and additional controlled-substance claims.

What the Medicaid Fraud Settlement Covered

The government alleged that the physician upcoded medical-service bills and billed for smoking-cessation counseling without sufficient documentation from January 1, 2012 through September 17, 2018. The claims went to Medicaid and Medicaid managed-care entities, which the government said relied on them to pay the physician.

The alleged physician upcoding concerned the level of service represented by the bill. The Attorney General described it as seeking reimbursement for more lucrative procedures than those actually performed. The counseling allegation concerned the records supporting a service billed to Medicaid.

The Attorney General’s Medicaid Fraud Control Unit conducted an audit and investigation with the U.S. Attorney’s Office for the Northern District of New York. According to the announcement, that work uncovered the claims at issue.

Separate State and Federal Payments

The state agreement called for $260,000 in Medicaid reimbursement and $308,750 in penalties. We find that telling: the penalty alone exceeded the reimbursement.

The companion federal civil agreement called for $331,250 to settle upcoding and smoking-cessation claims. It also covered certain claims under the Controlled Substances Act.

Why the Visit Level Matters

In fee-for-service billing, the mix of codes and the number of services billed for an encounter can change what a practice receives. That is why the visit note and the claim need to be read together: one describes the care, while the other asks the payor to compensate the practice for a particular service.

The 2020 Journal of Forensic and Investigative Accounting article A Forensic Accountant’s Guide to the Most Potent Federal Laws Used Against Healthcare Fraud describes false reimbursement requests that misstate the services or goods provided. It identifies claims for more expensive categories of care than were furnished as a recurring health care False Claims Act pattern. Applied to a higher visit level, the practical question is what work the bill says occurred and what work the patient record supports.

For an insider, the connection between those records is where knowledge of the practice matters. Someone who knows how the service became a billing code can help explain the difference between the clinical account and the payment request. We look at that connection alongside who performed the work, the service date and the payor that received the claim.

Smoking-Cessation Counseling and the Patient Record

The smoking-cessation allegation focused on counseling claims that were not sufficiently documented. It gives the patient record a separate job from supporting the medical visit’s level: showing the counseling service for which the practice sought payment.

For a clinician who documented the encounter or a biller who handled the charge, that is a specific question: what in the chart supports the counseling Medicaid paid for? We bring that knowledge of the encounter into the billing review.

What Evidence Does a Whistleblower Need?

A whistleblower’s useful evidence connects the submitted claim to the service date, patient record, actual work and people who knew how the bill was produced. We examine the connection between clinical records and billing with the person who understands the practice’s work, including how the service description became a claim for government payment.

The 2017 Journal of AHIMA article Busting Bad Medicine: a Call to Action Addressing Healthcare, Fraud, Waste, and Abuse identifies the treatment date, treatment type and nurse or physician signature as useful checks against false billing. It then makes a point that matters to anyone who knows what happened inside a practice:

Your knowledge can give those documents their meaning. A clinician can explain the care described in the note, and a billing employee can explain what the claim represented. We work with that account to connect the disputed charge, the payment and the decisions behind it.

The Extra Visit Charge in Skyline Urology

Skyline Urology agreed to pay $1,850,000 in a 2019 settlement over allegations that it billed Medicare separately for routine evaluation and management services already included in same-day procedures. The Justice Department’s settlement announcement described use of modifier 25 to claim the additional payment.

That case concerned an extra visit charge, while the Central New York matter included alleged higher service levels and insufficiently documented counseling. We want to know what the payment request added to the clinical story and who inside the practice could explain it.

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. We assess the potential whistleblower reward as part of the case we build with you, connecting the billing conduct you know to the government money involved.

You Know the Visit Behind the Bill

If you saw higher visit levels or counseling charges reach Medicaid without the supporting care or records, speak with our whistleblower experts. We bring physician billing knowledge to your account, build the case with you and find healthcare fraud whistleblower lawyers who understand how a practice turns care into claims. We stay beside you as we pursue your strongest Medicaid whistleblower case.