Michigan Vascular Stent Fraud: Unperformed Procedures and Fabricated Medical Records

A vascular surgeon in Bay City, Michigan, agreed to pay the United States up to $43,419,000 to resolve False Claims Act allegations involving bills for procedures never performed and services improperly billed separately. The Justice Department announced the civil settlement on May 25, 2023. For someone who knows the procedures behind those bills, the central question is whether the medical record describes the care that actually happened.

Stents Billed but Never Placed

The Michigan vascular stent fraud case puts the medical record itself at the center of hospital billing fraud. The allegation of unperformed procedures reaches beyond whether a code fits a written diagnosis. It reaches whether the treatment described in the paperwork occurred at all. In his plea, the surgeon admitted that he billed for placing multiple vascular stents in the same blood vessel, prepared medical records to justify that billing, and did not place those stents. He also billed for arterial thrombectomies, with records saying he found blocked arteries that justified them, and admitted that he often found no such blockages and performed no such procedures.

When the record itself is written to match the bill, a review that only checks the chart against the claim will not catch it.

A consulting firm brought the qui tam case behind the civil settlement. The firm’s announced share of the civil resolution was up to about $4.3 million. Its complaint compared the surgeon’s Medicare claims with the rest of his specialty.

The Complaint Compared One Surgeon With His Specialty

The whistleblower’s complaint alleged a striking mismatch between the surgeon’s Medicare billing and the work reported by other vascular surgeons. Its service-volume comparison put the scale in plain sight:

Medicare was paying for a volume of care that the complaint said one surgeon could not possibly deliver.

The complaint also alleged that the surgeon used the highest-level evaluation and management codes for nearly every patient. Those codes called for a comprehensive history, a comprehensive examination and highly complex medical decision-making. The alleged pattern extended from the number of services into the intensity of the visits billed.

Another comparison asked how much work the claims implied. The complaint alleged productivity eight to ten times that of even the busiest vascular surgeons, using the specialty survey’s 90th percentile as its benchmark.

The money followed the same pattern in the complaint’s account. It alleged an average Medicare payment per patient of $6,918, compared with $408 for the average vascular surgeon.

Modifier 59 Added a Separate Billing Allegation

Modifier 59 unbundling was another part of the government’s civil case. The United States alleged that the surgeon used the modifier to separate services that should have appeared together in a single claim, increasing reimbursement from federal health care programs.

That allegation concerns how services were charged. A bill can overstate what happened by claiming a procedure that never occurred. It can also increase payment by presenting services as separately payable when they belong together. The government’s civil allegations addressed both kinds of false billing.

For a coding or billing insider, the distinction makes the concern concrete. One question is what service the patient received. Another is how that service became the claim submitted for payment. The modifier sits at that second point, where the account of the encounter becomes a request for money.

What the Billing Pattern Leaves Unanswered

Claims comparisons identify where the clinical account needs closer attention. RAND’s 2024 report, Methodologies to Measure Upcoding in Provider Settings, reviewed 39 articles on measuring upcoding. Most examined coding intensity indirectly.

The report describes comparisons between billed visit levels and medical records containing the patient’s history, examinations, diagnoses and treatment options. That comparison gets to the Michigan complaint’s highest-level visit codes: what in the patient’s history or examination justified the level billed?

The 1999 Journal of AHIMA article Honest Mistake or Fraud? Meeting the Coding Compliance Challenge recommended checking whether a diagnosis justified a procedure and whether charges and length of stay fit the patient’s condition.

The article also described retaining the original codes, the codes used for the bill and the versions after billing, together with the reasons for changes. A final bill shows the code submitted. The earlier versions can show what changed and why.

Unnecessary Stents and Unplaced Stents Raise Different Questions

Medically unnecessary procedures concern treatment a patient did not need. This case concerned procedures alleged never to have been performed at all. In both, the relationship between the clinical evidence and the written justification matters.

At King’s Daughters Medical Center, operated by Ashland Hospital Corp., the government alleged that physicians falsified records to justify unnecessary coronary stents and diagnostic catheterizations. The hospital agreed to pay $40.9 million to resolve false-billing and physician financial-relationship allegations. The record could tell a convincing story about why a procedure was needed while the government questioned the truth of that story.

The EMH Regional Medical Center and North Ohio Heart Center case shows why the procedure insider’s position matters. A former manager of the catheterization and electrophysiology laboratory brought the whistleblower case. The government alleged that patients had heart disease but insufficient vessel blockage to require the angioplasty and stents they received. The medical question was specific to the vessel and the procedure.

The whistleblowers in the Saint Joseph London case described an even more direct comparison. Their first amended complaint alleged that imaging showed a much smaller blockage than a physician reported in one artery, while another reported narrowing was absent. The image and the written description were telling different stories, according to the complaint.

These cases show what a clinical or billing whistleblower can contribute. The analyst sees the pattern across claims. The clinical observer can speak to the vessel, the procedure and the account written afterward. Bringing those views together gets closer to the transaction the government paid for.

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

When the Stent Exists Only in the Record

Knowing that a billed stent was never placed gives you an account the paperwork cannot supply. Speak with our whistleblower experts about the procedures you know. We build your case with you from the clinical and billing evidence, bring in healthcare fraud whistleblower lawyers who know false medical billing, and stay alongside you through the case.