Complete Physician Services: The Obesity and COPD Codes Behind the Settlement

In the Complete Physician Services Medicare Advantage settlement, the Philadelphia primary-care practice and two physicians agreed to pay $1.5 million to resolve allegations involving unsupported morbid-obesity and COPD coding and improper Part B billing. Former employees brought the case. The government alleged that diagnosis codes increased insurers’ payments even when the patients’ records contradicted the diagnosis or failed to support it.

The Justice Department announced the settlement on May 25, 2023. Its Part C allegations covered submissions from January 1, 2015, through December 31, 2018. The case puts the practice’s own medical records at the center of the payment story: what condition did the record support, and what condition reached Medicare?

Morbid Obesity Codes Against the Recorded BMI

The government alleged that Complete Physician Services submitted morbid-obesity diagnosis codes for patients whose body mass index was under 35. The government said the recorded BMI did not medically support the diagnosis being reported.

The morbid-obesity allegation puts the contradiction inside the practice: its own charts held the measurement that challenged the code it submitted.

For a clinician or coder, the useful connection is between the recorded BMI and the diagnosis submitted for that patient. Our work starts with that connection and follows it through the submission and the decisions behind it. Someone who knows the chart can explain a discrepancy that a payment total alone would never reveal.

COPD Codes Without Medical Support

The government also alleged that Complete Physician Services submitted chronic obstructive pulmonary disease diagnoses that lacked medical support or appropriate medical documentation in many instances.

The obesity allegation pointed to a recorded measurement that conflicted with the code. The COPD allegation asked what medical evidence and documentation supported the condition reported. Both led to the same alleged result: increased Part C reimbursement to health insurance companies.

A clinical label has a second life once it becomes payment data. A practice employee’s knowledge of the visit record and the diagnosis submitted can connect those stages.

The Practice’s Codes and the Plans’ Payments

Complete Physician Services allegedly supplied unsupported diagnoses that increased Medicare Advantage insurers’ reimbursement. The payment route explains why a case against a physician practice can concern money Medicare pays to a health plan.

Medicare pays private plans a monthly amount for coverage. Through risk adjustment, eligible diagnoses are grouped into hierarchical condition categories, which contribute to a patient’s risk score alongside demographic factors. The score multiplies the plan’s base payment. A diagnosis in the practice’s records can therefore affect what the insurer receives for covering that patient.

Unsupported codes can increase what taxpayers pay without any change in the patient’s health. A study in Health Management Policy and Innovation, Diagnostic Coding Intensity for Medicare Advantage versus Fee-for-Service Populations, examined claims from 2010 through 2014. It compared the risk measure used for Medicare Advantage payments with an alternative diagnosis-based measure that did not determine those payments.

The measures produced similar results for traditional Medicare. For Medicare Advantage, the alternative measure reduced the apparent risk to approximately the traditional Medicare level. The paper’s conclusion connected coding intensity to money: plans may be using more intensive coding to push up risk scores and, with them, their payment rates.

An insurer can receive more money because a patient looks sicker on paper. The study helps explain why the diagnosis in a primary-care chart matters beyond the practice’s own bill.

The Same BMI Conflict Reached Insurer Cases

Cigna and Aetna also resolved allegations about morbid-obesity codes that conflicted with patients’ recorded BMI. Those cases place the insurer’s submission and correction decisions beside the practice’s role in generating diagnosis data.

In Cigna’s settlement announcement, the government alleged that Cigna submitted or failed to delete inaccurate morbid-obesity codes for patients below the same BMI threshold used in the Philadelphia allegation. The challenged payment years were 2016 through 2021.

The government alleged in Aetna’s settlement announcement that the insurer submitted or failed to delete morbid-obesity codes inconsistent with recorded BMI for payment years 2018 through 2023.

The recurring evidence is the disagreement between the patient’s record and the diagnosis used for payment. Complete Physician Services puts that disagreement inside the primary-care practice. The insurer cases extend the question to what happened when the code reached the plan, including whether an unsupported code stayed in place. A clinician, coding employee and plan auditor can each see a different part of that sequence.

Part B Bills for Care the Records Did Not Support

The Complete Physician Services settlement also covered allegations of unsupported Medicare Part B billing. Those claims concerned what the practice billed for visits and services, alongside the diagnosis codes that increased health plans’ payments.

The government alleged that the practice billed evaluation and management visits using CPT code 99214 without the level of care and complex medical decision-making the code required.

The practice also allegedly billed physician assistant services as “incident to” a physician’s professional services, including occasions when the physician was out of the country. A bill tied to a physician who was out of the country is the kind of detail a practice insider would recognize.

The government also challenged unsupported billing for pulmonary function tests, smoking cessation counseling and vaccine administration. The lung-function tests sit beside the COPD coding allegation in the same settlement. One concerned billing for services, the other the medical support for a diagnosis used to increase plan payments.

Former Employees Brought the Complete Physician Services Case

Former Complete Physician Services employees filed the False Claims Act qui tam case that the settlement resolved. They brought it on the government’s behalf. The practice and the two physicians agreed to the settlement together.

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

You Know What the Chart Actually Said

If you saw obesity or COPD diagnoses reach Medicare Advantage submissions without support in the patient’s record, talk with our whistleblower experts about the coding you witnessed. We build your strongest Medicare Advantage whistleblower case around that clinical knowledge, bring in Medicare Advantage whistleblower lawyers who understand provider coding, and stay beside you through the case.