Qin Medical: Routine Procedures Without the Records to Justify Them

The Qin Medical settlement required the practice and its vascular surgeon to pay $783,200 to the United States over Medicare billing for routine fistulagrams and angioplasties without documented clinical justification. They admitted that the surgeon routinely saw patients regardless of medical need and that the practice sought and received Medicare reimbursement without the required documentation. For the person who handled the appointments, patient records or claims, the case connects a familiar office routine to the government money it generated.

The Justice Department’s March 8, 2021 announcement concerned a surgeon practicing in Lower Manhattan and Far Rockaway, Queens. The U.S. Attorney’s Office for the Southern District of New York and the U.S. Department of Health and Human Services Office of Inspector General announced the resolution together. The announcement also described an expected additional New York settlement of $16,800.

The federal settlement amount reflected the government’s assessment of the defendants’ ability to pay. This was not the surgeon’s first fraud settlement: he had previously paid $150,000 to settle a civil fraud lawsuit involving his former employer and billing during 2010 through 2012. The whistleblower’s complaint described the earlier conduct as substantially similar. We see a familiar problem here: a previous settlement followed by another case over the same kind of conduct.

What Fistulagrams and Angioplasties Were Supposed to Show

The Justice Department explained that a fistulagram uses dye injected into a vein or artery to visualize blood flow. An angioplasty uses wires and balloons inside narrowed vessels to restore it.

The practice primarily treated patients with end-stage renal disease who were receiving dialysis. Medicare’s billing guidelines required specific, documented clinical problems to justify these vascular-access procedures, such as significant difficulty receiving dialysis properly. The clinical reason for intervening was part of what made the procedure payable.

That puts medical necessity fraud at the center of the case. The government alleged that the physician performed procedures as a matter of routine and misrepresented patients’ medical conditions in the records. In that account, the calendar supplied the procedure and the chart supplied the reason.

The Three-Month Schedule and the Civil Admissions

In the civil settlement, Qin Medical and its physician admitted that the physician often scheduled and saw dialysis patients approximately every three months, regardless of medical need. They also admitted that symptoms documented in the medical records, including the dialysis center’s and treating nephrologist’s records, were insufficient to justify numerous fistulagrams and angioplasties.

The admissions reached the payment decision, too. The physician knew Medicare would not pay without documented clinical justification, yet Qin Medical repeatedly sought and received reimbursement without it.

The criminal indictment charged that, during 2015 and 2016, the physician scheduled procedures three months ahead and, on multiple occasions, misrepresented patients’ conditions in their medical records to make symptoms appear to warrant treatment. The government’s civil complaint alleged the same conduct and that the practice billed Medicare for the procedures.

When the Images Contradict the Chart

The whistleblower’s complaint alleged a direct contradiction between the written justification and the procedure images. It said patients underwent procedures despite reporting no fistula or dialysis problems, while billing records falsely described blockages sufficient to support reimbursement. It further alleged that radiological images contradicted the physician’s written descriptions in all but a handful of cases.

The complaint reported that an expert reviewing the images found no indication for treatment in 89% of the cases reviewed. The image and the written description gave the allegation something concrete to turn on.

The scheduling account was equally specific. The whistleblower alleged that nearly every patient arriving for a possible fistulagram or angioplasty from November 2015 through April 2016 received one. According to the complaint, exceptions occurred only when another professional, such as a radiologist who might question proceeding, was present during the evaluation.

An insider’s knowledge can explain that difference between an appointment for an evaluation and a procedure that appears already decided. Who was present, what the patient reported and what the image showed each bear on the clinical explanation used to obtain payment. We build the case with the insider who can explain how those decisions reached the Medicare bill.

What Kept Patients Coming Back

The whistleblower also alleged that Qin Medical used transportation and routine copay waivers to support the flow of patients. The complaint said the practice often arranged limousine rides to and from the clinic to induce patients to undergo unnecessary procedures, then submitted the transportation costs for government reimbursement.

The complaint separately alleged systematic copayment waivers and resulting false government claims. It also alleged that the physician pressured patients to return by making them believe that missing repeat procedures would have serious consequences. These allegations widen the view inside the practice from the procedure room to the arrangements that kept the appointments filled.

What Evidence Does a Whistleblower Need?

We assess evidence of physician billing fraud by connecting the clinical reason for treatment, the procedure actually performed and the supporting records to the government claim. Qin Medical’s civil admissions specifically reached beyond its own chart to the dialysis center and the treating nephrologist. Those records mattered because they described the symptoms offered to justify the treatment.

A practice insider may understand how those entries were created, who supplied the clinical explanation and how it reached the health care claim. That knowledge helps us connect a discrepancy in a chart to the people and decisions behind the claim.

The 2017 Journal of AHIMA article Busting Bad Medicine: a Call to Action Addressing Healthcare, Fraud, Waste, and Abuse describes checking the treatment date, treatment type and nurse or physician signature against the patient’s record. It then makes the point that gives an insider’s account its value:

The same comparison appears in Tri-City Cardiology‘s vascular case. In its vein-ablation settlement announcement, the Justice Department alleged incorrect measurements or documentation of blood flow, vein diameter, symptoms and prior conservative treatment. Qin Medical’s admissions center on routine scheduling and insufficient documented symptoms. Tri-City’s allegations concern the measurements and history used to justify a different vascular procedure.

How Much of a Settlement Does a Whistleblower Get?

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. In Qin Medical’s case, a whistleblower’s False Claims Act lawsuit first brought the civil fraud allegations to federal law enforcement. We assess the potential whistleblower recovery around the government’s claims and the facts you can explain from inside the practice.

You Know How the Procedure Reached the Schedule

If you know why patients kept returning for procedures their records did not justify, speak to one of our Whistleblower Experts about the practice’s Medicare claims. We build the case with you around the appointments, clinical records and payment decisions, and bring in healthcare fraud whistleblower lawyers who understand vascular-procedure billing. We stay beside you through the process, turning what you saw into your strongest medical necessity whistleblower case.