Nursing Home Physician Visit Upcoding: Billing for Time the Doctor Allegedly Never Spent

In a Webster City, Iowa, nursing home visit upcoding case, a primary-care doctor agreed to pay $316,439 to resolve allegations that he billed Medicare and Medicaid for more intensive care than he provided. The Justice Department connected an unusually expensive billing pattern to surveillance, an administrator’s observations, and replacement treatment notes created after the originals had been shredded. The people who saw the visits and handled the charts knew a side of the business the claims did not show.

The doctor served as medical director of two nursing homes where the disputed billing occurred. The Justice Department announced the civil settlement on January 16, 2020. It covered routine nursing-facility visits from January 1, 2014 through November 30, 2018.

The Highest Visit Level Almost Every Time

The government said the doctor billed over 93% of his nursing-home visits to Medicare under the most intensive and expensive claim code. For the claims under investigation, the Justice Department said a doctor typically had to spend 35 minutes at the patient’s bedside and on the facility floor or unit to justify that level.

Medicare paid more than $94 for those claims. The least expensive code, for routine ten-minute visits, would have paid no more than $32. The alleged upgrade changed what Medicare paid without the more intensive service behind it.

The fee-for-service incentive was plain long before this case. A California Research Bureau report described it this way:

A Medicare contractor had already spotted the billing pattern. In July 2016, it sent the doctor a letter warning that his billing was significantly more expensive than other doctors’.

Surveillance Put the Claims on a Clock

According to the Justice Department, surveillance contradicted the time the doctor said he spent caring for residents. In sworn written answers submitted in July 2018, he claimed approximately 35 minutes of care for each of 12 patients at two nursing homes, concerning visits in 2017 and 2018.

For one date in October 2017, he said his visits began at 7:30 a.m. and finished at approximately 5:30 p.m. A federal agent watching that day placed him at the first home for a total of 47 minutes. The agent never saw him visit the second home. The first home’s administrator estimated that he spent approximately five minutes with each patient during his visits there.

The government described another comparison from February 2, 2018. The doctor billed nine claims for services to nine Medicare patients at a nursing home. Videotaped surveillance showed a total of 14 minutes on site.

A billing entry described extended care. The people and evidence outside the billing system described something much shorter.

Treatment Notes Shredded After Billing

According to the Justice Department, the doctor’s staff routinely shredded all nursing-home patient notes immediately after billing. When the audit arrived, he had no treatment records of his own for those patients.

He then asked nursing-home administrators and nursing managers for their patients’ charts to rebuild his own notes for the audit. The Justice Department described the replacement notes he provided as fraudulent records intended to cover up the overbilling.

The claims had already gone out, the original notes were gone, and the replacement account came later. A nursing home’s chart could supply information about a resident. It could not put the doctor in a building surveillance showed he never entered. The government said residents did not receive the care taxpayers paid for, and families could not know how much care he had actually provided.

The Medical Director’s Role and the Billed Visit

Nursing-home billing crosses separate records. The Centers for Medicare & Medicaid Services’ consolidated-billing guidance explains that physicians’ professional services may be separately payable during a Medicare Part A stay.

That is why the physician’s claim and the facility’s chart belong in the same review. Here, the facility administrators and nursing managers held charts the doctor later sought, and an administrator could describe the visits. Their view of the care helped test the account submitted for payment.

When the Claim Outgrows the Visit

The government’s complaint concerning Eye Care One alleged a closely related mismatch in nursing-home eye examinations. The optometrist allegedly documented examinations lasting five minutes or less as comprehensive examinations lasting 45 minutes. The complaint made the difference concrete:

The connection is the distance between the service recorded and the encounter staff could observe. The person working alongside a visiting provider may know how little of the claimed examination actually occurred.

A different route to inflated visit levels appeared in KareFirst’s nursing-home billing settlement. The government alleged that proprietary charting software automatically raised subsequent nursing-home visit codes. The alleged inflation happened inside the charting software, before the code reached the payer.

What Evidence Is Needed to Report Fraud?

For nursing-home visit upcoding, the useful evidence connects the billed service to the resident, the care delivered, and the people who knew what happened. In the Iowa case, that connection ran through claims, written answers about time, surveillance, an administrator’s observations, and the history of the treatment notes.

Our health care fraud review brings the visit note and facility chart together with the billed code, service date, claim, and any independent account of the provider’s work. Schedules, time records and contracts can help explain who was expected to do what. Billing employees may know how a visit became a claim; nursing staff may know what happened with the resident. We work with that firsthand knowledge to connect the healthcare decisions to the payment.

The Civil Settlement and Whistleblower Rewards

The U.S. Attorney’s Office began this civil case through its own investigation.

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

You Saw the Visits Behind the Claims

If you saw brief rounds become high-level visits on the bill, or saw treatment notes rebuilt after questions arrived, speak to one of our whistleblower experts. We build your strongest nursing home whistleblower case with you and bring in nursing-home fraud whistleblower lawyers who understand physician billing and clinical records. You bring the view from inside the facility or billing office, and we stay beside you through the case.