CityMD, Summit and Village: Insured Patients Billed to the COVID Uninsured Program

The CityMD COVID uninsured program settlement required CityMD to pay $12,037,109 to resolve allegations that it billed a federal program for COVID testing of patients who had health insurance. The government alleged that some patients already had insurance cards on file, and that CityMD also sent outside laboratories requisitions incorrectly describing insured patients as uninsured. For someone who handled registration, billing or lab orders, the point is familiar: information entered at the front desk can determine where the money comes from.

The Justice Department announced the civil settlement on June 7, 2024. The allegations covered testing from February 4, 2020 through April 5, 2022, and a CityMD patient brought the whistleblower case. This physician billing fraud case turned on what the practice said about the patient’s insurance when it sought government money.

What the COVID Uninsured Program Paid For

The Health Resources and Services Administration’s COVID Uninsured Program reimbursed health care providers for testing uninsured people, treating uninsured people diagnosed with COVID and administering vaccines to uninsured people. Payments generally followed Medicare rates. The patient’s insurance status was central to the program’s purpose: paying for care for people without coverage.

The patient’s complaint described the eligibility certification attached to those claims: providers attested, to the best of their knowledge, that the patient was uninsured when the care was given. That makes the payer field part of the claim’s substance. A practice could record the test correctly while allegedly giving the government a false account of who should pay for it.

How an Insurance Entry Reached an Outside Lab

The government alleged that CityMD submitted claims without adequately confirming insurance coverage, including for patients whose insurance cards it already held. It also alleged that CityMD caused outside laboratories to submit false claims by sending requisition forms that incorrectly marked patients as uninsured. The allegation reached both CityMD’s own billing and the information it supplied to another biller.

That second path matters in urgent care. As the complaint describes the workflow, CityMD collected specimens and sent them to outside clinical laboratories, which billed independently using the insurance information CityMD supplied. The requisition connected the office encounter to a separate laboratory claim. An insurance entry could therefore travel beyond the practice that created it.

We call that a remarkable definition of uninsured: a patient whose insurance card the practice already holds. For a registration or billing employee, the revealing comparison is between the coverage information the practice received and the status it sent onward.

The Patient Who Saw His Insurance Disappear

The whistleblower’s complaint alleged a specific change between check-in and the patient portal. During a July 2020 visit to a CityMD urgent care center in Union, New Jersey, the patient said he entered both primary and secondary insurance details on an electronic tablet, including insurer names and policy numbers. He then asked an administrator about a copayment:

According to the complaint, the patient later opened the portal and found his visit information, services and diagnosis accurately recorded, with one exception. His insurance information was missing, replaced by a payer entry reading “Uninsured Insurance.” He alleged that the administrator’s stated intention to delete the information explained the change he could see.

The complaint said CityMD sent his specimen to Quest Diagnostics for testing. From the altered insurance entry, the patient inferred that CityMD had supplied Quest with false uninsured information and caused a claim to the federal program. He also inferred from the administrator’s response that deleting insurance information was routine. The government’s settlement covered claims allegedly caused through erroneous lab requisitions.

The patient also alleged that he received neither a bill nor an explanation of benefits from CityMD, Quest or his insurers. The discrepancy he described was in the record of who would pay, even though nobody had sent him a demand for money.

The Practices and Management Companies in the Settlement

The signed agreement identifies the settling businesses as City Medical of the Upper East Side, PLLC, Summit Medical Group, P.A., Summit Health Management, LLC, and Village Practice Management Company, LLC. It calls them collectively CityMD and describes their operation of approximately 177 urgent care offices in New York and New Jersey.

The agreement identifies City Medical of the Upper East Side as the New York professional practice and Summit Medical Group as the New Jersey professional practice. Summit Health Management and Village Practice Management Company were the practice management entities. That division reflects a feature of the industry: professional entities deliver clinical services while management services organizations handle contracted administrative functions. For someone explaining a billing decision, the practice name and the management function can both matter.

What the Settlement Money Covered

The settlement credited $7,022,522 that CityMD had already repaid to HRSA in February 2022. The agreement set the remaining principal at $5,014,587, payable in installments. The agreement also credited CityMD for cooperation: the company hired a third party to help determine the government’s alleged losses, identified affected claims and made the earlier repayment.

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. In CityMD’s case, the agreement set the patient’s whistleblower share at 17%, more than $2 million. A patient who knew what he entered at check-in brought the case that produced that award.

CityMD’s Earlier Billing Settlement

CityMD’s 2018 billing settlement concerned services billed at a greater length or complexity than the work performed or documented, and uncredentialed physicians’ work billed under other physicians’ identifiers. The COVID uninsured-program case concerned a different representation: whether the patient had insurance.

What Evidence Does a Whistleblower Need?

For an uninsured-program case, the important evidence connects the patient’s actual coverage, the practice’s insurance entry, the laboratory requisition and the claim that reached the government. The CityMD complaint gives those connections a concrete starting point: what the patient entered, what an administrator said and what later appeared in the portal. A billing or laboratory insider may know how that entry became the payer information on a claim.

The Journal of AHIMA’s 2017 article, Busting Bad Medicine: a Call to Action Addressing Healthcare, Fraud, Waste, and Abuse, describes reviewing treatment dates, treatment details and clinician signatures when examining possible false billing. It also explains why the people behind the records matter:

That observation fits the patient account here: the administrator’s alleged statement helped explain the later portal entry. We bring the same attention to records that disagree and the people who understand why. Your knowledge of registration, insurance verification or laboratory billing may supply the connection that an isolated claim leaves unexplained.

You Know How the Payer Was Chosen

If you saw insured patients marked uninsured or coverage information changed before a lab order went out, speak to one of our Whistleblower Experts about how the payer was changed. We work with you to build your strongest healthcare whistleblower case around those decisions, bring in healthcare fraud whistleblower lawyers who understand practice and laboratory billing, and stay beside you through the case.