Hickory Physician Billing Fraud: The Operator Left, but the Nerve-Test Claims Continued

Hickory physician billing fraud involved more than $467,376 in fraudulent claims submitted and at least $210,120 paid, according to the Justice Department’s May 2, 2016 criminal-case announcement. That announcement describes the physician admitting in the criminal case that he added fictitious tests to real visits and invented entire visits. For someone inside a practice, the most revealing detail is what happened when the contractor left: nerve-conduction claims continued even though the physician lacked the equipment and expertise to perform the tests.

The admitted conduct ran from 2007 through 2014 and involved Medicare and Medicaid money. This physician billing fraud account turns on a practical question familiar to clinical and billing staff: what work could the office actually perform on the date shown on the claim?

What Are Some Examples of Fraud in Medical Practice?

The Hickory criminal case shows two examples of fraud in medical practice: adding a test that never happened to a visit that did, and billing for a visit that never happened at all. Each puts a different false account of care in front of the payer. In the first, a real appointment gives the claim something truthful to attach to. In the second, the encounter itself is invented.

That distinction matters in a fee-for-service practice, where more encounters and more services per encounter can each increase receipts. The billed service, its units, the place of service and the practitioner identified on the claim all describe what the payer is being asked to buy. An appointment on the calendar answers only part of that story when the claim also lists a diagnostic test.

The 2020 Journal of Forensic and Investigative Accounting paper A Forensic Accountant’s Guide to the Most Potent Federal Laws Used Against Healthcare Fraud describes factually false claims as reimbursement requests that misstate the services or goods provided. In its separate discussion of criminal health care cases, the paper describes tests never performed and office visits billed when the physician neither saw nor examined the patient.

Nerve-Conduction Claims After the Contractor Left

The contractor’s departure in February 2012 gives the nerve-conduction claims a concrete dividing line. The Justice Department’s announcement of the criminal case describes the physician admitting that those claims continued after the departure despite his lacking both the equipment and the expertise. The office was still billing for a capability it did not have.

We see the absurdity in that sequence: the person doing the work leaves, but the billing carries on. For the employee who knew the testing arrangement, the departure date can explain why later claims deserve attention. A claim names a service and a date. That employee can explain what changed inside the office before that date.

That is where contractor records, equipment information and test records become useful together. We would connect the contractor’s last working date with later billed service dates and examine what equipment and qualified personnel were available. The comparison puts the office’s actual ability to deliver the test beside its request for government payment.

What Evidence Does a Whistleblower Need?

A whistleblower in a case like this may know the contractor’s last day, the equipment available, or how an unperformed test reached the bill. The useful billing evidence connects that knowledge to the patient record, the billed service and the payment. Someone who scheduled the work may understand a discrepancy that is hard to see from the claim alone. We connect those records to the same service date so the account of what happened in the office reaches the government dollars at issue.

The Journal of AHIMA’s 2017 article Busting Bad Medicine: A Call to Action Addressing Healthcare, Fraud, Waste, and Abuse identifies the treatment date, treatment type and clinician signature as details to compare in a patient record. It also explains why a person who understands the work matters:

In this case, that insight points directly to the testing arrangement. An employee’s account of who performed the tests and what happened when that person left can give meaning to the dates in the billing records. We work with the insider to connect the operation they knew to the claims the practice sent.

When the Physician on the Claim Was Away

Pain Specialists, P.A. supplies a related example of the gap between a claim and the people available to do the work. In its guilty plea described by the Justice Department, the practice admitted billing under its physician owner’s National Provider Identifier while he traveled, for services requiring his personal consultation or direct supervision.

The relevant mismatch there was between the physician identity used for billing and the owner’s actual involvement. In Hickory, it was between billed nerve tests and the equipment and expertise available after the contractor left. Both accounts show why the people who know the working arrangements can explain what a claim conceals.

Your Knowledge of the Practice Has Value

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. For a practice insider considering a qui tam case, our work starts with the connection between the services billed, the government money and the people who knew what was happening. Your understanding of the daily work can supply that connection.

You Know When the Testing Stopped

If you know that a practice kept billing for tests after the person doing them left, speak to one of our Whistleblower Experts about the tests that kept getting billed. We work with you to build your strongest whistleblower case, bring in healthcare fraud whistleblower lawyers who understand physician billing, and stay beside you through the pursuit of a recovery.