Crossroads Treatment Centers: Routine Check-Ins Billed as High-Level Office Visits

In the Crossroads Treatment Centers fraud case, four clinics agreed to an $863,934 civil settlement over allegations that they billed routine substance use disorder check-ins as high-level office visits. The United States and Virginia alleged that the clinics knew those meetings did not support the code they billed. For someone who worked with the appointments, visit notes or claims, the question goes straight to the daily business: how did the visit in the clinic become the visit on the bill?

The Department of Justice announced the settlement on July 25, 2024. A former director of network management and contracting at Crossroads brought the whistleblower lawsuit that prompted the federal investigation.

What Code 99215 Represented in the Case

The government alleged that, from 2016 through mid-2023, Crossroads clinics billed Virginia Medicaid under code 99215 for regular treatment check-ins that fell short of the work the code represented. In its account of the case, the Justice Department described a visit involving at least two of three components: a comprehensive medical history, a comprehensive medical examination and medical decision-making of high complexity.

That description puts the allegation in terms a clinician or biller can recognize. The history, examination and decision-making were the substance behind the claim. The government said the clinics knew their regular check-ins did not meet those criteria and submitted the higher-level claims anyway.

The whistleblower’s complaint described the financial incentive plainly: Crossroads allegedly received a higher reimbursement rate than the services actually performed justified.

In the government’s account, the extra complexity was on the claim. We see a public health care program being charged for a higher-complexity office visit on paper.

Four Crossroads Clinics, One Virginia Medicaid Settlement

The settlement covered Crossroads Treatment Center of Petersburg P.C., ARS Treatment Centers of New Jersey P.C., Crossroads Treatment Center of Greensboro P.C. and Starting Point of Virginia P.C. The Justice Department identified them as part of the Crossroads chain headquartered in Greenville, South Carolina.

The amended complaint described Crossroads as an opioid use disorder treatment chain operating over 90 clinics when the complaint was filed in 2021. The four practices named in the settlement were part of that larger network.

The Justice Department’s Civil Division and the U.S. Attorney’s Office for the District of South Carolina handled the case.

What the Crossroads Settlement Allocated

The settlement allocated $356,891 to the United States and $507,043 to Virginia. Medicaid receives funding from both the federal government and the states, so the alleged billing reached both public payers.

What the Whistleblower Compared

The whistleblower’s amended complaint alleged that Crossroads’ appointment records and billing documents told different stories about the same visits. Its office-visit allegations describe a daily appointment list for a physician at a Virginia clinic and encounter superbills used to prepare claims for Medicaid managed-care plans.

According to the whistleblower, the appointment list identified patients, service dates and the time spent with the physician. The superbills supplied insurance information, the service date, provider, procedure and billing code. Matching those documents allegedly exposed a repeated discrepancy:

The complaint’s comparison joined the clinical and billing sides of the same encounter. A biller looking only at the superbill would see the code selected for payment. Someone familiar with the appointment list could point to the time the physician actually spent with that patient.

The alleged mismatch appeared when the documents were read together. The whistleblower also alleged that some daily billing represented more patient time than the physician could have supplied during the hours available at the clinic.

The Earlier Warning Described in the Complaint

The complaint also alleged that Crossroads had received a warning about inadequate documentation for office-visit billing at a Pennsylvania clinic.

According to the whistleblower, a November 2018 Medicare contractor letter described a review of 40 randomly selected claims. The complaint said none met Medicare guidelines because the submitted documentation lacked the required history, examination and medical-decision-making components. The review concerned code 99213.

The whistleblower used that letter to allege that Crossroads had notice of problems with its office-visit billing.

Who Sees the Gap Between Visit and Bill?

An employee who understands the clinical notes may see the missing history or examination. Someone handling appointments may know the physician’s available time. A billing or contracting employee may understand how the visit became a claim and who received a payer’s questions about it. Those perspectives meet at the same service date.

If you recognize that split in your own work, our healthcare whistleblower experts can assess how your knowledge connects the encounter, payment and decisions inside the company. You bring the view from inside the operation; we work with you on the case it may support.

The Office-Visit Pattern in Other Treatment Cases

At Springbok Health, the government alleged high-complexity or prolonged evaluation-and-management billing when, at most, less expensive counseling had occurred. The clinic and its owner settled those allegations. As in Crossroads, the allegation concerned the distance between the service delivered and the service billed.

In a separate case against Ultimate Treatment Center and its physician, the government alleged billing for evaluation-and-management work that had not occurred. The government’s complaint described cloned notes supporting office-visit claims on days when a patient had take-home medication and no office encounter.

These cases follow different routes to the same billing question. One concerns the level of the professional service. Another concerns whether the encounter happened at all. For a person inside an addiction-treatment business, knowing what the clinician actually did can explain a claim that looks complete on its own.

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 Crossroads, the settlement expressly provided a reward from both the federal and Virginia recoveries to the former director whose lawsuit prompted the investigation.

You Know the Visit Behind the Code

If your clinic’s claims describe care that the appointments and notes cannot support, talk with our whistleblower experts about what you saw. We build your case around the clinical work, the payment and the people directing the billing, and bring in behavioral health whistleblower lawyers who understand Medicaid office-visit claims. We stay beside you as your knowledge of the clinic becomes a case for recovering public money.