Preventive & Diagnostic Medical Center: The 43-Hour Billing Day

Preventive & Diagnostic Medical Center and its physician owner agreed to pay $693,490 in a billing fraud settlement to resolve allegations of upcoding, impossible days and services the physician never provided. The agreement designated $364,995 of that total as restitution. The allegations connected the codes on the bills to the physician’s available time, including days when he was outside the country.

The practice is in Ramsey, New Jersey. The Justice Department’s February 22, 2024 announcement described alleged conduct from January 1, 2017 through June 1, 2022. For a coder, scheduler or clinician, the question behind those allegations is familiar: did the billing describe the care patients actually received?

Upcoding the Visit’s Complexity or Duration

The government alleged that the practice and its owner billed evaluation and management services under codes describing more complex care or longer visits than patients received. The settlement agreement places those allegations among claims knowingly submitted to Medicare. In the government’s account, Medicare was asked to pay for more expensive care than patients received.

For someone working inside a practice, the useful comparison is the visit as documented and the visit as billed. We connect the clinical record to the selected code, the person responsible for that selection and any instruction to change it. A clinician may know what care was delivered, while a billing employee may know how that care became a different level on the claim.

Medicare Claims Behind an Impossible Day

The settlement agreement describes impossible-day billing as codes attributed to the physician whose associated time collectively exceeded 24 hours in a day. The government alleged that the defendants regularly submitted Medicare claims for services the physician had not provided through this kind of billing. Its example was March 2, 2018, when the time associated with the billed CPT codes exceeded 43 hours.

That figure measures the time associated with the codes submitted for the physician. All of those services were attributed to the same person on the same date. We see a straightforward absurdity in the government’s allegation: the claims gave the physician more working time than the day contained, and Medicare got the bill.

The daily total points to the encounters that need explaining. The evidence behind an impossible-day claim connects the codes to the original treatment records, schedules, signatures and people who actually performed the work. Someone who knows the practice’s daily workflow can explain how a claim acquired the physician’s name and how much involvement the physician actually had.

Services Billed While the Physician Was Abroad

The travel allegation concerns services attributed to the physician on days when he was outside the United States. The Justice Department’s announcement describes services purportedly provided to New Jersey Medicaid beneficiaries. The signed federal agreement also lists services during the physician’s absence among its Medicare allegations.

For an insider, that brings the travel calendar into the same account as the patient chart and claim. We compare the service date, payer, location and actual treating practitioner with the physician’s recorded involvement. A staff member who covered the schedule may know who saw the patient, while the billing record shows whose service the government was asked to pay for.

What Evidence Does a Whistleblower Need?

A whistleblower’s evidence connects particular submitted claims to the care, time and people behind them. In a case involving inflated visit levels or absent services, we work through the treatment date, description of care, signatures and staffing alongside the bill. Your account explains what those records meant inside the practice.

The 2017 Journal of AHIMA article Busting Bad Medicine: A Call to Action Addressing Healthcare, Fraud, Waste, and Abuse describes checking treatment dates, treatment descriptions and signatures against the patient’s health record. It then makes the point that gives an insider’s knowledge its value:

The witness supplies the working history of those records: who entered the visit, who selected the billing level and who could change it. We use that account to follow a disputed claim through the practice, including any warning that reached the people directing the billing.

The Audit and the Response

A practice’s billing reviews can show what management learned about its claims and what it did afterward. The chapter Implementing a Physician Practice Compliance Program, published by Jones and Bartlett in 2011, calls for detailed documentation of audit findings, trend analysis, independent reviewers and documented corrective action. It treats operational review as work across scheduling, billing, medical records and staffing.

Those connections matter when the concern is a repeated billing pattern. We examine which claims an audit questioned, who received the findings and what the practice submitted afterward. For a health care employee who saw a warning followed by the same billing, the response can help explain what the people directing the claims knew.

The Same-Day Problem in Hospitalist Billing

IPC Hospitalists of Michigan and Team Health Holdings reached a separate settlement announced in October 2023 over allegations that included high-level inpatient evaluation and management upcoding and volumes of services too high to perform in a day. The government also challenged claims attributed to the same provider on the same day in Michigan and Indiana, contending that services to Michigan beneficiaries had not been rendered.

The connection to the Ramsey practice is the comparison between billed work and a physician’s actual availability. The calendar, location and individual encounter make the allegation concrete. An employee who knows where the physician was and how the schedule worked can help explain claims that otherwise appear only as a daily total.

What a Physician Billing Whistleblower Can Bring

A physician practice qui tam case can connect the person who understood the workflow with the claims it produced. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. Our whistleblower experts connect what you know about the visits, schedules and billing decisions to build your strongest physician billing case.

You Know Who Was There

If you know how a practice billed visits that its physician could not have performed, speak to one of our Whistleblower Experts about the claims you saw. We connect your knowledge of the care and the calendar to the government payments, bring in healthcare fraud whistleblower lawyers who understand physician billing, and stay beside you through the case.