Hudson Valley Hematology-Oncology: Nurse Schedules, Physician Signatures and Waived Copays

In the Hudson Valley Hematology Oncology settlement, the practice agreed to pay $5,314,000 over waived copays billed to Medicare and unsupported extra visit charges to Medicare and Medicaid. The partnership admitted billing for additional evaluation and management services without documenting the separate work. For someone who knows the nurse schedule, signs the progress note or enters the charge, this case shows how those pieces can tell very different stories about the same appointment.

Hudson Valley treated people with cancer and blood disorders through offices in New York’s Hudson Valley region. The case began with a former accounts-receivable representative responsible for coding and charge entry. The Justice Department’s October 21, 2016 announcement described conduct from 2010 through June 2015 and said the government joined the whistleblower’s lawsuit. The Health and Human Services Office of Inspector General investigated the case.

Copays Waived in the Ledger, Included in the Medicare Bill

Hudson Valley admitted routinely waiving Medicare copayments without an individualized, documented financial-hardship determination or exhausting reasonable collection efforts. It also admitted including those waived amounts in its Medicare billings, producing higher reimbursement than it was entitled to receive. This copay waiver fraud reached both the patient’s account and the government’s payment.

The government’s complaint alleged that the billing system recorded waivers as “write-off,” “down coding for Medicare,” and “professional courtesy.” It described one patient who received 34 treatments without a copayment collected or a documented reason for the waivers. The complaint also alleged automatic waivers on certain visit charges, even when a patient had not asked for one, recorded as “99212 courtesy write off.”

In one example, the government alleged that Hudson Valley submitted a $125 claim for each billed visit while waiving the patient’s copayment. Medicare reimbursed a percentage of the submitted amount, so leaving the waived portion in the claim increased the government’s payment. We call that a courtesy at taxpayers’ expense.

The 2020 Journal of Forensic and Investigative Accounting paper A Forensic Accountant’s Guide to the Most Potent Federal Laws Used Against Healthcare Fraud points to documented financial need or failed reasonable collection efforts as grounds for a copayment waiver. In Hudson Valley’s case, the government alleged that frequent visits, high balances and unpaid insurance amounts prompted waivers without supporting patient documentation. The government also alleged that the routine waivers were kickbacks to Medicare patients under the Anti-Kickback Statute. The alleged inducement was the forgiven copay itself, before it ever reached the Medicare bill.

The Nurse Schedule and the Stack of Charts

The government’s complaint alleged that Hudson Valley kept separate daily schedules for physician appointments and routine nurse services. Patients on the nurse schedule came for chemotherapy, injections or blood withdrawals and typically did not see a doctor during those appointments. The schedule showed who was expected to do the work before anyone signed a note.

The complaint called them the “M.D. schedule” and the “Chem/Inj/RN schedule.” It alleged that the combined patient volume typically made it impossible for a physician to examine or manage everyone on both. At the end of the day, the practitioners who treated patients on the nurse schedule allegedly left those patients’ charts on a physician’s desk for signatures.

The progress note had a place to claim physician time, and the government alleged that doctors filled it in despite typically not seeing those patients. The complaint described the step that connected the signature to the additional billing:

According to the complaint, Hudson Valley used those certifications to bill Medicare or Medicaid for additional evaluation and management services. The alleged physician involvement appeared in the completed note even though the nurse schedule and treatment history told a different story. The signature was doing work the physician allegedly had not done.

The Extra Visit Behind the E/M Code

Hudson Valley admitted adding evaluation and management charges to routine procedures without documenting significant, separately identifiable E/M services. It also admitted billing E/M services without documenting that they were medically necessary or actually performed. The same question sits behind same-day E/M billing fraud: what additional work supports the additional payment? In this case, the complaint connected the codes to what happened in the treatment room and what appeared afterward in the chart.

Back then, the complaint described code 99211 as the lowest-level established-patient E/M service, typically used for nursing services. It described code 99212 as a higher level involving a problem-focused evaluation. Infusion, injection and chemotherapy procedure payments already included the lower-level service. Billing a higher-level E/M service alongside them required significant, separately identifiable work beyond the procedure’s usual care.

The government’s patient examples put the alleged mismatch in concrete terms. One patient’s notes described nurse-performed infusions for anemia, with no additional treatment, while signed certifications claimed at least ten minutes of physician evaluation and management time. Hudson Valley allegedly added code 99212 to the procedure claims. In another example, the notes described blood draws without an additional service, yet the claims again included a separate visit charge.

Skyline Urology later agreed to a settlement over alleged routine E/M charges added to same-day procedures. The Justice Department alleged that Skyline used Modifier 25 to obtain separate Medicare payments for work already included in the procedures. Both cases direct attention to the extra visit on the bill and the clinical work supposed to support it.

The resolution also reached the practice’s future billing controls. Hudson Valley entered a corporate integrity agreement requiring a compliance program and five years of monitoring by the Health and Human Services Office of Inspector General.

What Evidence Does a Whistleblower Need?

For this kind of billing case, useful evidence connects the claim to the actual care: the appointment schedule, treatment record, person who performed the service, signed note and submitted charge. We examine those connections with you using the billing rules that applied to the service date and setting. Your knowledge of how the practice moved from an appointment to a signed note can explain a discrepancy that the final claim conceals.

The 2017 Journal of AHIMA article Busting Bad Medicine: A Call to Action Addressing Healthcare, Fraud, Waste, and Abuse describes checking treatment dates, treatment details and nurse or physician signatures in the health record. It then makes the point that matters when the disputed signature is already on the page:

Hudson Valley’s whistleblower worked in coding and charge entry, where the care described in a record became a bill. That working knowledge is the starting point for a physician practice whistleblower case: what the records say, how they came to say it and who understood the difference. We build the case with you around what happened between the treatment room and the billing desk.

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. Hudson Valley’s separate share agreement allocated a whistleblower reward of $1.06 million to the former employee.

You Know What Happened Before the Note Was Signed

If you know why a nurse-only appointment acquired a physician visit charge, or why a waived copay stayed in a Medicare bill, tell our whistleblower experts what happened inside the practice. We build the case with you around the care, the records and the billing decisions, bringing in physician billing fraud whistleblower lawyers who understand oncology practices. We stay beside you as your knowledge of the health care delivered becomes the evidence behind the case.