Eye Care One: Brief Visits, Lengthy Exams on the Bills

In the Eye Care One fraud case, the practice and its former owner agreed to a $275,000 civil settlement over allegations that they billed the most expensive nursing-home eye examinations after brief visits or no exam at all. Employees described which patients the optometrist saw, how little time he spent with them and whether he brought photography equipment. The government’s complaint connected those observations to the bills sent to public health care programs.

The Justice Department’s settlement announcement identified Eye Care One’s companies and its former owner as the settling parties. The practice was based in Augusta, Georgia. The government identified Medicare, Medicaid and Railroad Retirement Medicare as the affected programs.

What Eye Care One Allegedly Billed

Eye Care One allegedly submitted claims for lengthy, comprehensive examinations while its optometrist spent minutes with patients. The government’s civil complaint described contracts under which the practice provided eye care at no cost to the nursing homes, then billed the residents’ insurers. The facility arranged access to patients. The eye-care practice sent the claims.

The complaint identified CPT code 99306 as the highest-paying initial nursing-facility examination level it discussed. That code called for a comprehensive history and examination and complex medical decision-making. The government alleged that visits documented as 45-minute comprehensive examinations lasted five minutes or less, sometimes only seconds.

In its 1997 report Fraud and Abuse in the Health Care Market of California, the California Research Bureau identified an incentive in fee-for-service payment to schedule more examinations than medically necessary. In the Eye Care One allegations, the bill described the expensive service while the patient received the abbreviated visit.

The Visit Did Not Match the Claim

At Glendale Nursing Home, the complaint said, a visit lasting approximately three hours generated claims representing nearly 22 hours of examination time. The government’s comparison came from the administrator’s arrival and departure times and the examinations claimed for 29 patients.

That is why the nursing home’s account of a visit matters alongside the practice’s examination notes.

The complaint also alleged a way of identifying patients who could not speak for themselves:

In the government’s account, residents least able to speak for themselves went without exams while taxpayers were billed. Families did object, according to the complaint. It alleged that the optometrist answered complaints about missed examinations by saying the patients had forgotten being examined. The government also described documented complaints from patients themselves.

Eye Photographs the Staff Could Not Find

Eye Care One also allegedly billed for eye photographs that employees never saw taken and could not find. The complaint identified CPT codes 92285 for external ocular photography and 92250 for fundus photography, which images the retina.

A former employee who coordinated nursing-home contracts said the optometrist stopped bringing optometry equipment to visits. The complaint alleged that he brought neither an ocular camera nor a fundus camera. It also alleged that, when he did take pictures, he used an ordinary camera instead of the specialized equipment.

In describing the billing requirements for these services, the complaint identified the images or proof that digital images existed, an order explaining the medical reason for the test, its findings and its effect on treatment. The government alleged that a sample review found none of that documentation in the patients’ files.

What Evidence Is Needed to Prove Fraud?

For nursing-home eye-exam billing, the useful evidence connects the visit, the service documented, the claim and the people who knew what happened. The government’s complaint drew on nursing-home administrators, technicians, a former contract coordinator, billing staff, patients and families. Each saw a different part of the same transaction.

We examine the facility’s visit records alongside the practice’s examination notes and technician schedules. In this case, the government alleged that technicians prepared patients before the optometrist arrived, that he told staff their preparation time could be billed, and that he sometimes directed them to skip dilation to speed visits. Those allegations give the schedules a specific purpose: separating the technician’s work from the examination the claim represented.

The complaint alleged that Eye Care One and its former owner presented 4,847 claims across the examination and photography codes from January 1, 2008 through February 24, 2011. We connect the claimed service and patient to the clinical record, image files and payer’s response. A technician may know what happened in the room while a billing employee knows how it became a claim.

The government alleged that several employees raised concerns with the optometrist and billing managers about the examination and photography codes in 2009 and 2010. The government’s account included earlier Medicare instruction about the level of service and medical necessity. Staff objections and billing guidance can connect a discrepancy to the people responsible for it.

The nursing-home setting also makes the identity of the biller important. Under Medicare’s consolidated-billing framework, the facility bills for many services during a covered Part A stay, but physicians can bill separately for their professional services. The government’s complaint described the practice billing insurers directly under its nursing-home contracts.

The Same Documentation Problem in Other Resident Care

Park Avenue Medical Associates’ psychiatric-services settlement concerned another practice treating patients in nursing homes and other care settings. The company admitted inadequate documentation of diagnostic examinations and repeated examinations without showing they met the billing rules.

For an insider, the connection is concrete: repeated examination claims can be compared with the clinical account of what happened at each visit. In Eye Care One, the government’s allegations went further, to examinations and photographs that employees said never happened.

What the Civil Settlement Resolved

The Justice Department announced the Eye Care One civil settlement on August 28, 2015. Eye Care One and its former owner agreed to pay the United States to settle False Claims Act allegations that they billed for care they provided inadequately or never provided at all.

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

You Saw the Visit Behind the Bill

If you know the eye-care visits were brief, the photographs were missing or staff objections reached the billing office, talk with our whistleblower experts. We build the case with you around the care, the claims and the decisions behind them, and bring in healthcare fraud whistleblower lawyers who understand Medicare eye-care billing. We stay beside you throughout the case.