Complete Physician Services: A Physician on the Bill, a Physician Abroad

In the Complete Physician Services fraud settlement, the Philadelphia primary care practice and two physicians agreed to pay $1,500,000 to resolve allegations of unsupported Medicare Advantage diagnoses and improper Medicare Part B billing. The alleged mismatches reached from a diagnosis the medical record could not support to physician-assistant services billed incident to a physician’s services while the physician was out of the country. Someone inside the practice could see the care and the billing telling different stories.

The Justice Department announced the settlement on May 25, 2023. Both sets of allegations covered January 1, 2015, through December 31, 2018, but they concerned different ways of increasing government payments.

Medicare Advantage Diagnoses That Increased Plan Payments

The government alleged that Complete Physician Services submitted unsupported morbid-obesity and chronic obstructive pulmonary disease diagnoses that increased Medicare Advantage payments to health insurance companies. In this part of the case, the disputed information described how sick the patient was, and the increased reimbursement went to the plan.

For morbid obesity, the government identified patients whose body mass index was under 35 and alleged that the diagnosis lacked medical support in those circumstances. For COPD, it alleged that diagnoses lacked medical support or appropriate medical documentation in many instances. Those allegations put the patient’s actual condition and the support in the chart at the center of the payment question.

The economics explain why the diagnosis matters even when the office visit stays the same. Medicare Advantage diagnoses can affect a plan’s risk-adjusted revenue without changing the office-visit allowance. A practice’s share of that money depends on its fee, capitation or risk-sharing contract. We follow the diagnosis from the encounter to the plan submission, and the money through the contract that pays the practice.

Coding instructions drove the allegations in the separate case involving the similarly named Complete Health Partners Holdings. In that company’s Medicare Advantage settlement announcement, the government alleged that incorrect coding guidance and prompts led doctors to add unsubstantiated chronic diagnoses, increasing payments that plans shared with the practice-management business. That case shows how an unsupported diagnosis can begin with an instruction inside the business.

Part B Claims That Outran the Work

The Part B allegations concerned what Complete Physician Services billed for visits and other services. The government alleged that the practice submitted claims unsupported by medical documentation to maximize its reimbursement.

Office Visits Billed at a Higher Level

The government alleged physician upcoding through evaluation and management code 99214 for visits that lacked the required level of service and complex medical decision making. The visit code represented a level of work that, according to the government, the care did not support. For an insider, the useful comparison is between the visit that occurred, its documentation and the code submitted for payment. The requirements in force on the service date belong in that comparison.

Physician-Assistant Services While the Physician Was Abroad

The government also alleged improper incident-to billing for physician-assistant services, including occasions when the physician was out of the country. We see the problem: physician participation on the bill, a physician abroad.

The Medicare Benefit Policy Manual connects incident-to services to an initial physician service, continuing active participation in treatment and the required supervision. The Medicare Claims Processing Manual supplies the payment distinction: qualifying physician-supervised incident-to claims may use the physician allowance, while direct physician-assistant claims generally use 85% of that allowance.

An absent physician also lay at the center of the criminal case against Pain Specialists, P.A. In its corporate guilty plea, the company admitted billing services under its physician owner’s identifier while he traveled, when personal consultation or direct supervision was required, as the Justice Department’s account of the plea explains. For an insider who knows the office schedule, the physician’s whereabouts can help test the participation the claims represent.

Counseling, Tests and Vaccine Administration

The Complete Physician Services settlement also covered alleged unsupported billing for smoking-cessation counseling, pulmonary-function tests and vaccine administration. We connect each billed service to the health care record, the date and the person who performed it. An employee who knows how counseling, testing or vaccine administration was documented can explain the gap between the work and the claim.

What Evidence Does a Whistleblower Need?

Useful evidence of physician billing fraud connects the submitted diagnosis or claim to what happened in the practice. For these allegations, that means the clinical support for the diagnosis, the billed visit level, the actual practitioner, the physician’s location and the documentation for the service. Different employees may see different parts of that account through coding, patient care, scheduling or billing.

The Journal of AHIMA’s 2017 article Busting Bad Medicine: a Call to Action Addressing Healthcare, Fraud, Waste, and Abuse connects billing review to treatment dates, the care documented and clinician signatures. It also makes a point that a stack of records can miss:

We want to hear from the person who can explain the discrepancy: who actually saw the patient, how the code was selected or what the schedule showed. That account gives the claim and chart a context they cannot supply by themselves. Healthcare billing records become much more useful when someone understands how they were made.

Does the Government Pursue Small Primary Care Practices?

Yes. In announcing this settlement, the Department of Health and Human Services Office of Inspector General said it investigates potential Medicare Part C fraud regardless of the practice’s size or the scheme’s complexity. The allegations here reached the diagnoses and service claims of a Philadelphia primary care office.

Former Complete Physician Services employees brought the qui tam case that the settlement resolved. The U.S. Attorney’s Office for the Eastern District of Pennsylvania investigated the case with the Department of Health and Human Services Office of Inspector General.

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. We work with practice insiders to connect what they know about the care, coding and supervision to the claims for government money. That is where clinical and billing experience can become the foundation of a whistleblower case.

You Know Who Saw the Patient

If you saw unsupported diagnoses submitted or physician billing that did not match who was there, talk with our whistleblower experts about the practice. We build your strongest whistleblower case with you and bring in physician billing and Medicare Advantage whistleblower lawyers who understand how those records connect to government payments. We stay beside you as your partners throughout the case.