DOCS Medical Group: Allergy Retesting, Physician Absence and COVID-Day Visits

In the DOCS Medical Group settlement, the Connecticut practice and its physician owner agreed to pay $4,267,950 to resolve allegations of unnecessary allergy care, unsupervised services, billing under an absent physician’s name and COVID-day office visits never provided. Those allegations reach different parts of a practice’s working day. Allergy staff may know why a patient returned for testing, a scheduler may know who was abroad, and a billing employee may know how a test became an office-visit claim.

The Justice Department announced the civil settlement on December 15, 2022, covering claims to Medicare and Connecticut Medicaid. DOCS operated more than 20 facilities throughout Connecticut, offering primary and urgent care, allergy testing and treatment, and COVID testing. Its owner and chief executive was a physician specializing in pulmonology. The Office of the Inspector General for the Department of Health and Human Services and the Connecticut Office of the Attorney General investigated the case.

DOCS and its physician owner also entered a three-year Integrity Agreement with the inspector general’s office at the Department of Health and Human Services. The agreement was designed to ensure future compliance with federal healthcare program requirements.

Unnecessary Annual Allergy Retesting

The government alleged that DOCS and its owner billed Medicare and Medicaid for medically unnecessary annual allergy retesting between January 1, 2014, and November 11, 2018. This branch of the settlement concerned whether patients needed the repeated tests. The patient’s need for a test, not the calendar, had to justify the claim.

For someone working in allergy care, the repeat order, the testing schedule and the clinical explanation belong in the same story. We want to understand who decided a patient needed another test and how that decision reached the claim. A calendar can explain when a patient returned. The clinical record has to explain why the billed service was necessary.

Immunotherapy Without the Required Supervision

The immunotherapy allegations covered October 1, 2016, through September 30, 2017. The government alleged that DOCS and its owner submitted claims for treatment that was medically unnecessary and lacked direct physician supervision. That raised a separate question from annual retesting: who was available to supervise the allergy work being billed?

In explaining the requirements behind the case, the Justice Department said allergy tests and the preparation of allergy immunotherapy required a physician in the same office suite, immediately available to assist. The treatment record and the staffing record therefore address different parts of the government’s allegation.

A Physician on the Claim, Abroad on the Service Date

The government alleged that DOCS and its owner billed services as the physician’s work between January 1, 2014, and January 1, 2019, on dates when he was traveling internationally. According to the government, he neither performed nor supervised those services. The government said lower-level providers did the work, and those providers typically receive lower Medicare and Medicaid reimbursement.

We see the absurdity in that allegation: the physician’s name was doing work the physician was not. The payment question connects the person who treated the patient to the identity used on the bill. A staffing schedule, the original clinical note and the submitted claim can tell different versions of the same encounter.

That is why incident-to billing requires more than finding a physician’s name on a chart. The Medicare Benefit Policy Manual calls for the practitioner to provide an initial personal service and stay actively involved in treatment, along with the required supervision.

COVID Tests Billed With Office Visits Never Provided

The COVID allegation concerned level-three evaluation and management services billed on the same days patients received COVID tests. The government alleged that DOCS and its owner submitted those claims to Medicare and Connecticut Medicaid between April 1 and December 31, 2020, even though the office visits were not provided. The test brought the patient into an encounter. The office-visit claim added work that, according to the government, never happened.

What Evidence Does a Whistleblower Need?

A whistleblower needs evidence connecting the claim to the care and the decisions behind it. For these allegations, that means the repeat-testing order and clinical reason, the immunotherapy record and supervisor’s availability, the actual worker and billed physician, or the COVID encounter and the office visit claimed. We work with you to connect those records to what Medicare and Medicaid paid.

The 2011 Jones and Bartlett chapter Implementing a Physician Practice Compliance Program describes an operational audit that reaches across scheduling, registration, billing, collections, staffing and medical records. It also calls for comparing the clinical documentation with the codes used. That is a useful way to understand this case: a code review reads differently when the staffing record says the named physician was away.

The chapter also identifies a problem that a practice’s compliance staff may recognize. The people affected by a finding can have power over the report itself:

If you saw a billing finding changed before it reached management, your knowledge may explain why the final report tells a different story from the underlying records. We examine that decision alongside the claims it concerned, including who knew what the original review found.

The Same Billing Gap in Other Practices

Complete Physician Services faced a similar allegation about physician-assistant services billed under a physician who was abroad. In its settlement announcement, the Justice Department also described unsupported office-visit billing. The common issue is the connection between the clinician’s actual involvement and the service represented to Medicare.

In a separate case involving Sparrow Medical Group, the government alleged that advanced-practice-provider services were billed as physicians’ incident-to services without meeting the required conditions. The whistleblower’s complaint described the mismatch in the charts:

You Know What Happened in the Exam Room

If you know why patients were retested, who covered for an absent physician or how COVID tests acquired office-visit charges, speak to one of our whistleblower experts about the billing you saw. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. We remain your partners throughout the case, building it with you and bringing in physician billing whistleblower lawyers who understand medical necessity, supervision and office-visit claims.