Physician Partners of America: Testing Profits, Visit Mandates and Four Qui Tam Suits

In the Physician Partners of America fraud settlement, the company, its founder and its former chief medical officer agreed to pay $24.5 million over allegations of unnecessary testing, improper physician compensation and a false pandemic-relief loan statement. The allegations reach into decisions an insider sees: who orders the tests, who profits, how often patients must return and which billing level management demands.

The Justice Department announced the settlement on April 12, 2022. Physician Partners of America, known as PPOA, was a Tampa-based practice management company managing pain groups in Florida and Texas. It also indirectly owned the toxicology and genetic laboratories that billed the tests.

The government’s allegations connected the management company’s instructions, physicians’ compensation, laboratory orders and bills to government health care programs. Following that chain explains why the case reached beyond the physician whose name appeared on a test order.

Testing Profits Before Patient Need

PPOA allegedly paid physicians 40% of the profits from the presumptive urine drug tests they ordered. The government said those payments tied to lab referrals violated the Stark Law, the physician self-referral law. The settlement agreement describes compensation based on net profits attributable to each physician’s qualitative urine testing orders, which the government alleged led to false Medicare claims.

The testing allegations followed the same money into the exam room. According to the Justice Department, PPOA required physicians to order multiple urine tests at once, before deciding whether testing was necessary or reviewing the initial test result to decide whether additional testing was warranted. The release calls the initial testing presumptive and the additional testing definitive. PPOA’s affiliated toxicology laboratory allegedly billed federal programs for the highest testing level. The agreement describes a protocol requiring the same tests for every patient, with medical assistants ordering them without treating-physician review.

The genetic and psychological testing allegations followed a similar pattern. The government alleged that PPOA required them before patients saw a physician, without first determining whether they were medically necessary. The agreement identified Medicare, TRICARE, Veterans Affairs, federal employee health benefits and federal workers’ compensation programs in the unnecessary-testing allegations. We see the absurdity in the alleged sequence: the order came before the patient’s need had been assessed, and the bill followed anyway.

Financial incentives are part of the clinical story. The Robert Wood Johnson Foundation’s 2008 synthesis, Physician Self-Referral and Physician-Owned Specialty Facilities, reviewed the relationship between physicians’ financial interests and use of services:

The synthesis points to chart review as a way to assess whether services were clinically appropriate. That makes the patient-level details in PPOA’s case especially useful: the initial result, the decision to order more tests and the treating physician’s review. For an insider who knows the testing protocol, those details connect a compensation formula to what happened to a patient and what the government was charged.

More Visits, Higher Codes

PPOA allegedly replaced its monthly visit schedule with unnecessary evaluation and management appointments every 14 days after Florida suspended non-emergency procedures during the COVID-19 pandemic. The Justice Department said the company also instructed physicians to use inappropriate high-level procedure codes. The agreement describes twice-monthly telemedicine visits intended to replace revenue lost when elective pain procedures stopped, regardless of patient need.

The evaluation and management allegations covered April 2020 through November 2021 and claims to Medicare, Veterans Affairs and Florida Medicaid. For someone inside scheduling or billing, the alleged practice connects a management instruction to both the number of visits and the level billed for each one. The high-level visit coding and the extra appointments were separate ways of increasing the bill. In the government’s account, lost procedure revenue became a reason to bring patients back more often.

Local Anesthesia Billed as Monitored Anesthesia Care

The agreement also alleged that PPOA administered local anesthesia but billed Medicare for monitored anesthesia care to obtain higher reimbursement. It puts the anesthesia record beside the claim: what the patient received and what PPOA represented to Medicare. It was a separate billing allegation from the visit mandate.

The PPP Certification

The PPP allegation concerned a $5.9 million Paycheck Protection Program loan. The government alleged that PPOA falsely certified on April 10, 2020 that it was not engaged in illegal activity while it was overbilling federal healthcare programs. The loan came from Centennial Bank, backed by the Small Business Administration.

We see the contradiction in what the government alleged: PPOA sought pandemic relief by denying illegal activity while overbilling federal health care programs. The application put that denial in writing.

Four Qui Tam Suits, One Settlement

Five current or former employees brought the claims resolved through four qui tam suits. The government agreed to join parts of the employees’ cases, and one settlement resolved their claims. The Justice Department’s Civil Division and the U.S. Attorney’s Office for the Middle District of Florida coordinated the resolution with federal investigators.

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. In this case, employees’ claims reached across a practice-management business, its pain groups and its laboratories. That is why a person’s knowledge of the orders, compensation or billing instructions can matter even when their job covers only part of the operation.

What the Integrity Agreement Required

PPOA entered a five-year corporate integrity agreement with the Health and Human Services inspector general. It required order forms to record why each test was ordered, including the diagnosis code and the results’ diagnostic relevance. Reviews had to identify unusual testing patterns and providers who failed to review results promptly or use them to adjust care.

Independent claims reviews also had to check medical necessity, documentation, coding and reimbursement. When a reviewed claim produced an overpayment, the reviewer had to examine the systems and processes that generated it. These requirements return to the questions at the center of the allegations: why was the test ordered, did its result affect the patient’s care, and what did the government pay for?

What Evidence Does a Whistleblower Need?

In a case about testing and visits like PPOA’s, useful evidence connects compensation terms and management instructions with patient orders, clinical records and submitted claims. The records behind the billing show different decisions: the formula used to pay a physician, the reason recorded for a test, the review of its result, the appointment schedule and the code billed. The payer and service date connect those decisions to particular government claims.

Someone in a laboratory may know when orders arrived and whether a physician reviewed the initial result. Someone in a pain practice may know why the visit schedule changed or who required the higher code. We work with that knowledge to connect what happened inside the business to a physician-practice whistleblower case.

You Know Who Set the Testing Rules

If your pain practice’s testing orders, compensation formula or visit schedule followed revenue targets, talk with our whistleblower experts about what you saw. We build the case with you and bring in healthcare fraud whistleblower lawyers who understand laboratory referrals and physician billing. You have a partner from the first conversation through the pursuit of the government’s recovery.