Pain Specialists, P.A.: A Guilty Plea for Claims Under an Absent Physician’s NPI

Pain Specialists, P.A. agreed to a $240,000 civil settlement with the United States and New Jersey over absent-physician billing allegations and entered a guilty plea to health care fraud in a separate criminal case. In its guilty plea, the company admitted billing under its physician owner’s National Provider Identifier while he was traveling, for services requiring his personal consultation or direct supervision. For the employee who knew who was in the office and who actually saw the patient, the claim could tell a very different story from the day’s work.

The New Jersey pain practice operated in Northfield, Vineland and Cape May Courthouse. The Justice Department announced the corporate plea and civil settlement on March 20, 2025.

What Pain Specialists Admitted in Its Guilty Plea

In its guilty plea, Pain Specialists admitted using its physician owner’s NPI to bill for services requiring his involvement while he was traveling and out of the office. The criminal conduct covered dates between November 2015 and January 2020. The owner specialized in anesthesia and pain management, and the practice billed Medicare, Medicaid and private insurance plans under his number.

The criminal information to which the company pleaded guilty explains what the claims represented. They had to identify the service performed, its date, the patient and the rendering physician or healthcare professional. The NPI identified the professional in the claim, and other practitioners at Pain Specialists had their own numbers. The choice of whose number appeared was part of the account the practice gave the insurer.

For the services at issue, the information said payment required the professional whose NPI appeared on the claim to examine the patient in person or be available to directly supervise the rendering provider. The criminal information put the insurers’ payments for the services billed under the traveling owner’s number at approximately $58,365. We see the absurdity in that account: the physician’s billing identity stayed at work while the physician was away.

The Civil Settlement Covered a Longer Period

The United States and New Jersey alleged that Pain Specialists improperly billed non-physician services under a physician’s identity from January 1, 2014 through November 9, 2020. The civil agreement describes claims listing a physician as the rendering provider when a non-physician practitioner provided the service and no physician was present in the office.

The governments alleged violations of Medicare’s incident-to billing requirements and Medicaid’s requirement that providers bill under their own NPI. Those allegations put the actual worker and the billed identity at the center of the civil case. The criminal plea concerned the owner’s number during his travel, while the civil agreement reached a longer period of claims for non-physician work.

The agreement allocated $126,225 to the United States and $113,775 to New Jersey. It also required the practice to give up seeking payment for the covered billings from patients or other payers. That term matters to the person behind the claim: the practice agreed to resolve the government billing allegations without passing those covered bills along to the patient.

Why the Billed NPI Matters

The physician’s billing identity can affect the payment for another practitioner’s work. Under the Medicare Claims Processing Manual’s payment provisions, direct nurse practitioner and physician assistant claims generally use 85% of the physician fee-schedule allowance, while qualifying physician-supervised incident-to claims may use the physician allowance. That payment structure gives the billing identity financial value.

The treatment record describes the care. The claim also represents who performed or supervised it under the payer’s requirements. For this kind of case, we connect those records to the service date, setting and actual supervision.

The 2020 Journal of Forensic and Investigative Accounting paper A Forensic Accountant’s Guide to the Most Potent Federal Laws Used Against Healthcare Fraud explains the payment problem through medical tests billed without required physician supervision. Its analysis treats that supervision as part of what qualifies the service for Medicare payment. That is the distinction in Pain Specialists’ guilty plea: the bill represented physician involvement the practice had not supplied.

What Evidence Does a Whistleblower Need?

For an absent-physician billing case, useful evidence connects the claim to the actual practitioner and supervision. The claim’s service date and NPI can be compared with the treatment record, staff schedule and physician’s travel. Someone who worked in the practice may know who saw the patient, who was available to supervise and how the owner’s number reached the claim.

A scheduler may understand the office coverage, a practitioner may know who performed the service, and a billing employee may know how the rendering-provider field was selected. We put those accounts alongside the records to understand how the practice presented the visit for payment. That is where knowledge of the daily workflow becomes useful evidence about government money.

The Journal of AHIMA’s 2017 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. It then makes the point that matters to the person who was there:

The Pain Specialists agreement itself connects records with people. It requires cooperation with government investigations, including efforts to make current and former employees available for interviews, and production of records concerning the practice’s investigation of the covered conduct. The people who understand how a claim was made can explain what the entries mean.

The Same Absence in Another Practice’s Claims

Complete Physician Services faced a similar allegation about physician-assistant work billed incident to a physician’s services while the physician was abroad. In its May 2023 settlement announcement, the Justice Department described that allegation among several billing and diagnosis allegations resolved by the practice and two physicians.

Former employees brought that qui tam case. In both cases, the billing account turned on where the physician actually was: admitted absence at Pain Specialists, alleged absence at Complete Physician Services.

What a Practice Insider Holds

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. We work with practice insiders to connect their knowledge of patient care, staffing and billing decisions to the claims for government payment. A person who understands why a physician’s number appeared on the bill may hold the explanation the payment record leaves out.

You Know Who Was in the Office

If you saw the office operate while an absent physician’s number kept reaching Medicare or Medicaid, speak to one of our whistleblower experts about whose number went on the bill. We connect your knowledge of the clinical work and billing decisions to the government claims, bring in physician billing whistleblower lawyers who understand supervision disputes, and stand beside you as we build your strongest physician billing whistleblower case.