Neurobehavioral Medicine Consultants: The Admissions, Stays and Visits Behind the Medicare Claims

The Neurobehavioral Medicine Consultants fraud case resulted in a $549,092 False Claims Act settlement over allegations of medically ineligible admissions, delayed discharges, nonexistent visits and Medicare billing at unsupported higher rates. Two psychiatrists and their practice group agreed to settle the case. For someone who worked with these patients, the allegations reach from the decision to admit a patient to the visit Medicare was told occurred. The person who knows the care may see something the bill conceals.

The U.S. Attorney’s Office for the Southern District of Ohio announced the settlement on December 9, 2020. The Medicare claims at issue ran from January 2013 through December 2019. Both doctors treated patients at Cambridge Behavioral Hospital in Guernsey County, Ohio. One also owned Neurobehavioral Medicine Consultants and served as the hospital’s medical director.

We see an ugly mismatch in these allegations: patients kept longer than necessary, visits billed without happening. More time in the hospital, visits only on the bill. Taxpayers were being asked to pay for both.

Four Allegations Behind the Medicare Claims

The United States alleged that the doctors admitted ineligible patients, prolonged stays and billed for unsupported care:

1. Medically ineligible admissions. The government alleged that the doctors admitted patients who were medically ineligible for inpatient care.
2. Improperly delayed discharges. The government also alleged that the doctors delayed patient discharges. An explanation for admission does not answer why the patient continued to need inpatient treatment later in the stay.
3. Services and visits that did not occur. The government alleged that the doctors billed Medicare for work they did not perform. A patient can be present in a hospital while a billed professional visit never happens.
4. Higher rates unsupported by the records. The government separately alleged billing at rates the records did not support.

The admission, the decision to continue hospitalization, the professional encounter and the billed rate each offer an insider a different view of what Medicare was asked to buy.

Why the Hospital Day and the Professional Visit Matter Separately

Medicare’s inpatient psychiatric facility payment model uses an adjusted daily payment for active inpatient psychiatric treatment. Professional services have their own payment requirements. The hospital day and the psychiatrist’s work therefore need to be understood separately, even when they concern the same patient.

Medicare’s inpatient psychiatric facility payment program adjusts its daily payment for factors including the patient’s age and qualifying diagnoses, along with facility factors. That payment structure explains why the continued need for a hospital day matters financially.

Admission certification and later review address the need for active treatment. The federal certification requirements distinguish the initial basis for inpatient care from the continuing need for it.

Professional billing adds another question. Medicare pays for defined professional work as well as facility care, as its mental health coverage guide explains. For a claim about a psychiatrist’s visit, the patient’s presence in a bed answers only where the patient was. The encounter and the work claimed still need their own account.

This is why we want to understand what happened on the ward as well as what reached billing. Someone familiar with the admission decision may explain one allegation. Someone familiar with the doctor’s visits may explain another. Both perspectives concern the care behind the claim.

The Practice, the Treating Doctors and the Medical Director

Neurobehavioral Medicine Consultants provided mental health services and substance abuse treatment to patients in several states, according to the settlement announcement. The government identified the two doctors as practicing psychiatrists with the company and treating psychiatrists at Cambridge. The practice owner also held the hospital’s medical-director position.

That combination matters because the case reaches both clinical decisions and professional billing. We would want to understand each decision in its own setting: who assessed the need for admission, who decided that care should continue, who furnished the claimed visit and how the claim described it.

Cambridge Also Appeared in a Separate Hospital Settlement

Oglethorpe and its Ohio treatment facilities, including Cambridge Behavioral Hospital, agreed to a separate $10,250,000 settlement announced on March 5, 2021.

The Settlement Payment and the Whistleblower Opportunity

The doctors agreed to pay the United States to resolve allegations about both the decisions to hospitalize patients and the services billed during their care.

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. Your knowledge of how the care became a claim is the starting point for our work with you.

What Evidence Is Needed to Prove Fraud?

We work with insiders to connect the care patients needed and received with what Medicare was billed. In a case involving these allegations, that means understanding the admission assessment, the reason a stay continued, the professional’s encounter with the patient and the documentation supporting the billed service.

For a clinician, that may begin with a discharge decision that did not fit the patient’s progress. For someone in health care billing, it may begin with a claimed service that the clinical record did not support. We bring those perspectives together to understand the decisions behind the claims and develop the whistleblower case with you.

You Know the Care Behind the Claim

If you saw patients kept in hospital unnecessarily or Medicare billed for visits you know never happened, speak with our Whistleblower Experts about the decisions behind those claims. We build the case with you and bring in healthcare fraud whistleblower lawyers who understand psychiatric admissions and professional billing. You will have us beside you from the first conversation through the pursuit of a recovery.