Prolonged E/M Fraud: Practitioner Time That Cannot Be Reused

Prolonged services billing fraud means knowingly charging for extra practitioner time that was never spent or that the practice has already counted toward another billed service. When Medicare pays for invented minutes, taxpayers cover work nobody did. The patient record, the practitioner’s day and the other services billed have to support the charge. If you see prolonged-service charges attached to visits whose time you know, you may know where the extra minutes came from.

An Anchorage rheumatologist’s criminal plea agreement describes the mechanism plainly. She admitted making false statements in medical records about how long she treated patients and what treatment she provided. Her office manager knew those statements were false, and they knowingly submitted claims for prolonged services that were not provided. The invented time was already in the medical record before it became a request for payment.

How the E/M Time Is Chosen

Physician upcoding can inflate either the complexity of a visit or the time behind it. Prolonged-service billing adds a narrower question: did the practitioner perform enough additional qualifying work to support the extra charge?

Since January 1, 2021, office evaluation and management levels have used medical decision making or the reporting practitioner’s qualifying total time on the service date. The Centers for Medicare & Medicaid Services office-visit fact sheet explains the change from the older selection rules. The length of the history and examination no longer chooses the office visit level.

For a time-based claim, we examine what work the practitioner actually did and when. A long medical history can make a note look substantial while saying little about the additional time claimed. The billing question is the qualifying work behind the selected code, including whether the practice selected the base visit by time when the prolonged-service rule requires it.

CPT and Medicare Use Different Prolonged-Service Rules

Medicare’s prolonged-service rules differ from the CPT rules, including the office code CPT 99417. The payer, the setting and the date of service determine which time rule belongs beside the claim. A threshold taken from a commercial coding guide can put the wrong starting point into a Medicare review.

The base office visit must be selected using time for this Medicare add-on. The Medicare E/M guide issued in May 2026 sets these first-unit thresholds for Medicare’s office prolonged-service code G2212:

Further units require complete additional 15-minute increments. The first add-on follows the qualifying base visit, and every subsequent unit needs its own additional time. That distinction matters when a billing system repeatedly adds the same prolonged-service charge: the underlying time has to support each claimed unit.

Hospital and observation visits use G0316, nursing-facility visits G0317, and home and residence visits G0318, each with its own Medicare conditions. The same May 2026 guide puts the first additional critical-care unit, 99292, at 104 cumulative minutes. We match the claimed time to the setting’s rule, because an office threshold cannot explain every extra charge.

Which Practitioner Minutes Count?

Office time selection concerns the reporting practitioner’s qualifying work on the service date. Clerical work and time already attributed to separately billed services cannot supply that same practitioner’s E/M time. A patient’s time in the practice and the practitioner’s qualifying time answer different questions.

The separate-service exclusion is particularly important where a visit also produces procedure charges. We examine the work supporting the procedure and the work supporting the additional E/M claim together. If the practice has included the procedure’s already-billed time in the prolonged-service total, the same work has supplied more than one request for payment.

Shared facility work presents another way to reuse minutes. Under Medicare’s split or shared visit guidance effective January 1, 2024, overlapping time counts once. The records identify both clinicians, and the practitioner performing the substantive portion signs and dates the record.

For that review, the useful account distinguishes each practitioner’s work from time spent together. Adding two clinicians’ entries can otherwise turn a shared interval into extra billable time. We follow who performed the work, which minutes overlapped and how the billing system arrived at the total it submitted.

What Evidence Does a Whistleblower Need?

A whistleblower’s account is strongest when it connects the patient record, the submitted claim, the practitioner’s schedule and the decisions that produced the bill. Those records answer different questions. The chart describes care, the claim asks for payment, and staff may know how one became the other.

We begin with the particular service: its date, payer, setting, practitioner and claimed time. The original chart and any later changes show how the account of the encounter developed. Billing instructions and the submitted claim show which part of that account became a charge. When your concern is that someone added time after the visit, the person who made or directed that change matters alongside the final entry.

We put the claimed minutes back into the practitioner’s day, against the schedule, staff assignments, travel and other services billed that day. We use those comparisons to examine the particular discrepancy you saw, including whether the same period appears in more than one time total.

The Journal of AHIMA’s 2017 article, Busting Bad Medicine: a Call to Action Addressing Healthcare, Fraud, Waste, and Abuse, connects documentation of treatment dates, treatment type and signatures with the need for witnesses. Its point matters especially when the time entry itself is false:

The Health and Human Services Office of Inspector General used a specialty-adjusted screen in its 2012 E/M report to identify physicians billing higher-level services. Its 2014 study added professional-coder review of medical records. That progression explains why we pair a pattern in claims with the charts underneath it. The distribution locates the high billing. The encounter records let us examine what the billed work actually involved.

A signed time statement is part of what we examine. Your knowledge of the work, the staffing and the billing instructions can explain how that statement came to be there. The Anchorage plea shows why that distinction matters: both the time entry and the resulting claim were part of the admitted conduct.

When the Billed Day Cannot Fit the Calendar

The Justice Department alleged that the time associated with a New Jersey physician’s billed codes exceeded 43 hours on March 2, 2018. The physician and Preventive & Diagnostic Medical Center agreed to pay $693,490 to resolve allegations of higher-level or longer-duration E/M claims and Medicaid services billed while the physician was abroad.

No calendar has room for that billed day. The useful next question is which services supplied those hours and what the practitioner actually did. A reconstruction connects the coded time to the individual encounters, their settings and the rules in effect then.

In a separate Michigan hospitalist settlement announced in 2023, IPC and Team Health agreed to pay $4,384,618 to resolve allegations that they billed work volumes that could not reasonably have been performed in a day. The government also alleged same-provider, same-day claims in Michigan and Indiana, contending that services billed for Michigan beneficiaries were not rendered. An insider who knows the assignments and locations can explain the conflict in a way that a billing total alone cannot.

When the Extra Charge Comes From the System

Prolonged-service concerns in healthcare billing can lead back to whoever controlled the billing instructions or the software. Other physician-billing complaints show why we examine those decisions alongside the clinical note. A repeated charge can have a repeated source inside the practice.

The government’s complaint against IPC alleged that the hospitalist bonus calculation began with monthly amounts billed, after salary and benefits. The government alleged that lower-billing physicians faced pressure to catch up with their peers. That puts the billing instruction beside a financial incentive. In a time-based inquiry, we want to understand what the practice rewarded and what staff were told to put on the claim.

In its complaint against Vohra Wound Physicians Management, the Justice Department alleged that a notation about another wound automatically generated a separate E/M claim alongside a debridement procedure. The government’s description identifies the precise trigger:

The complaint also alleged that senior management received an outside audit’s findings but retained overpayments and delayed correcting the system. That connects the claimed service, the software and the response to a warning. The broader allegations of fabricated clinical reasons for payment show how a medical record can carry the billing system’s assumptions into the claim.

Other complaints describe instructions doing similar work. A whistleblower complaint concerning National Spine and Pain Centers alleged that management directed mid-level providers to use CPT 99214 for monthly visits the whistleblower described as low complexity. A CityMD whistleblower complaint alleged that routine flu shots generated level-three E/M bills to government health care programs. For a prolonged-service inquiry, the corresponding question is who chose the extra time and how that choice reached the claim.

The chapter Implementing a Physician Practice Compliance Program, in Jones and Bartlett Publishers’ 2011 Health Care Administration, examines the difficulty of having billing staff or an office manager audit their own work. It also explains that responsibility for compliance needs authority to act. For us, that adds a practical question to the time records: who could correct the billing, and what happened when someone raised the discrepancy?

What a Prolonged-Service Fraud Case Can Show

A prolonged-service False Claims Act case connects a false representation about time to government payment and to what the people responsible knew. We look at what they knew, ignored or deliberately avoided learning. We examine the claimed minutes, their effect on payment, the instructions behind them and the response to warnings.

The insider’s contribution can be the connection between those parts. You may know why the chart says the visit lasted longer, who required the extra charge or why a correction never reached the billing system. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

When You Know Where the Minutes Came From

If you see time added to visits or reused across claims, speak with our whistleblower experts about the billing you know. We use the clinical work, the claimed minutes and the decisions behind them to build your strongest prolonged-service whistleblower case. We bring in physician-practice whistleblower lawyers who understand time-based billing and stay beside you through the process.