KareFirst: The Software Behind the Higher Visit Codes

KareFirst and its former owners agreed to pay $1,992,482 in a fraud case over allegations that its charting software automatically upcoded nursing-home visits billed to Medicare and Medicaid. The company allegedly required its nurse practitioners to use the system despite knowing it produced false claims. The person seeing the resident entered the visit. According to the government, the company’s software turned that entry into a more expensive bill.

KareFirst Management was an independent nurse practitioner group that contracted out practitioners to skilled nursing facilities across the Chicago area. A former employee brought the qui tam case, and the United States joined it before settlement. The Department of Justice announced the resolution on June 18, 2024.

How KareFirst’s Software Allegedly Raised the Visit Code

The government alleged that KareFirst’s proprietary charting software automatically raised subsequent nursing-home visit codes in the CPT 99307-99310 series. The conduct covered by the resolution ran from January 1, 2013 through February 21, 2020. Practitioners charted their patient visits in the company’s system, which allegedly generated the upcoded claims KareFirst submitted for payment.

The allegation put the company’s control over the system at the center of the case. KareFirst allegedly developed the software, required its use and submitted the resulting claims. The government also alleged that KareFirst knew what the software was doing. That connects the charting requirement to the bill and to a decision inside the business to keep using the system.

The financial incentive is familiar. In Fraud and Abuse in the Health Care Market of California, the California Research Bureau’s 1997 report explained that fee-for-service income depends on the frequency and complexity of services. It described upcoding as billing for a more expensive procedure than the one performed. In KareFirst’s alleged version, the higher code came from the software, not from more care at the bedside. Taxpayers were paying for a level of visit the underlying care did not support.

The Visiting Practice Had Its Own Billing Role

A practitioner working inside a nursing home can generate a professional claim separate from the facility’s bill. Under Medicare’s consolidated-billing framework, a covered Part A stay bundles many services into the nursing home’s payment, while a physician’s professional services can be billed separately.

That boundary matters to someone working at the bedside. The resident’s nursing-home chart, the visiting practitioner’s note and the practice’s claim can sit in different parts of the business. In the KareFirst allegations, the nurse practitioner group supplied both the charting system and the claims submitted to Medicare and Medicaid. Understanding a billing rule built into the software therefore means following the visit through the practice’s system, including what happened after the practitioner entered it.

The Former Owners Also Backed the Payment

KareFirst’s two former owners personally backed the settlement payment obligation, together and individually. The payment commitment reached beyond the corporate entities.

The settlement covered payments to the United States and the States of Illinois and Indiana. The agreement also allocated part of the recovery to the Railroad Retirement Board.

What Is the Reward for a Medicare Fraud Whistleblower?

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. The KareFirst agreement set the former employee’s whistleblower reward at eighteen percent of the recovery.

An employee’s knowledge matters in a health care billing case built around a required charting system. The person who knows the workflow understands how a patient entry became a claim, and who decided it would work that way.

What Evidence Is Needed to Prove Fraud?

For software-driven visit upcoding, the evidence connects the care actually provided, the practitioner’s entry, the code the software produced and the claim sent for payment. Our work on the difference between the chart and the claim also asks who controlled that process and what they knew about the result.

A practitioner may recognize a visit billed at a level the examination did not support. A billing employee may see the code submitted and the payment received. Someone who knows the software can explain how the system translated the clinical entry into that code. Those accounts address different parts of the same transaction.

We compare the encounter documentation with the claim for that resident and service date. Schedules and time records can help connect the practitioner to the visit. Contracts can identify the business supplying and billing for the service. Where software chose the code, we examine the relevant settings and change history alongside the clinical entries and resulting bills.

KareFirst allegedly required the software despite knowing it generated false claims. Instructions about using the system, objections to its output and management’s response help us trace why the billing continued. We work through those connections with the people who understand the care and the system.

When the Software Also Writes the Supporting Record

In the Vohra Wound Physicians Management wound-care billing case, the government alleged that an electronic medical record system controlled billing and inserted fabricated procedure descriptions to make the chart appear to support surgery. Its complaint put the alleged manipulation plainly:

The comparison is control over what the system tells the payer. KareFirst’s case concerned allegedly inflated visit codes. Vohra’s complaint described software creating the information used to support a procedure claim. A chart and a bill can agree because the same program supplied the information in both. The clinician’s account of the actual care gives that apparent agreement something independent to answer to.

You Know What the Practitioner Entered

If you know how a nursing-home visit became a higher code, talk with our whistleblower experts about the system behind the bill. We build the case around your knowledge of the care, the software and the decisions inside the practice, and bring in healthcare fraud whistleblower lawyers who understand professional billing. We stay beside you through the case, connecting what you saw to the claims the government paid.