Southeast Orthopedic Specialists: Moving the Visit to Make It Billable

In the Southeast Orthopedic Specialists Jacksonville 2016 settlement, the orthopedic group agreed to pay $4,488,000 over allegations of unnecessary ultrasound-guided injections and other false healthcare claims. The government described a practice billing for separate services that had not occurred, claiming physician supervision without a physician present or verified, and moving follow-up visits to make them separately billable.

For someone inside an orthopedic practice, the question runs through the daily work: does the bill describe the care, or has the care been arranged around the bill?

What the Jacksonville Settlement Covered

Southeast Orthopedic Specialists was a Jacksonville, Florida orthopedic medical group. The Justice Department announced the settlement on December 7, 2016, following an investigation by the Department of Health and Human Services. The government said the practice sought reimbursement for millions of dollars in questionable healthcare claims. Medicare and other federal health care programs were the payers, putting taxpayers behind the bills.

The resolution also included a three-year integrity agreement for claims review, according to the Department of Health and Human Services’ Office of Inspector General.

How the Alleged Billing Worked

The government described seven practices that changed what federal health care programs were asked to pay for. Some concerned the service itself. Others concerned the supervision, certification or timing used to support payment.

Electronic Health Records and Postoperative Visits

The government alleged that Southeast Orthopedic Specialists certified that it met meaningful-use standards for electronic health records even though it had not met them.

The scheduling allegation was more tangible. The government alleged that the practice moved follow-up operative visits from twelve weeks after surgery to fourteen weeks, in what the announcement called an effort “to bill for a separate visit outside the normal Medicare 90 days Diagnosis-Related Group charge.” In the government’s account, the appointment moved so the practice could charge Medicare again. The calendar served the bill.

Physician Supervision and Separate-Service Modifiers

The government alleged that the practice knowingly billed services as incident to physician supervision when no physician was present or when there was no verification of a physician’s presence. The supervision represented on the claim was the issue: who was actually there when the service took place?

Modifier 25 concerned a separate evaluation and management service. According to the government, the practice used it even when that separate service had not occurred.

Modifier 59 concerned whether procedures could be billed separately. The government alleged that the practice used it to bill two procedures when they should have been billed as one.

A 2020 paper in the Journal of Forensic and Investigative Accounting, A Forensic Accountant’s Guide to the Most Potent Federal Laws Used Against Healthcare Fraud, draws a useful distinction between falsely certifying that payment conditions were met and falsely listing the services provided. It also identifies missing required physician supervision as a potential Medicare payment problem. Applied here, the distinction is concrete: a claim can misstate the care a patient received, or the physician supervision behind that care.

The paper focuses on the claim for payment, rather than the underlying activity alone. For these allegations, that connects decisions in the treatment room and the scheduling office to the money the practice sought from the government.

Ultrasound Guidance and Physical Therapy Necessity

The ultrasound allegation was that Southeast Orthopedic Specialists routinely used and billed for ultrasound-guided injections even without medical necessity.

In a physician’s office, equipment expense can be included in the payment for the physician’s service. That is how a medical device becomes part of a billing case: here, the alleged problem was the routine use of ultrasound guidance and the claims it generated.

Physical therapy raised a similar necessity question through a different billing representation. In the allegations resolved in 2016, the government said the practice used Modifier KX to bill beyond the Medicare physical therapy cap despite the absence of medical necessity.

What Evidence Is Needed to Prove Fraud?

For the practices alleged here, the evidence connects what happened in the office with what the practice represented when seeking payment, and what it knew about the difference. We work through that connection with the insider who understands the services, the scheduling or the billing decisions. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. The Jacksonville announcement names no whistleblower case.

For the Jacksonville allegations, the evidence questions include who scheduled the follow-up visits, who appended Modifiers 25, 59 and KX, and who recorded or verified physician supervision. Those decisions need to be connected to the services actually provided and the claims submitted.

Southwest Orthopaedic Specialists in Oklahoma is a different company from the Jacksonville practice and has its own case.

You Know What Happened Before the Bill

If you saw routine ultrasound billing, supervision claimed without a physician, or visits moved to create another charge, speak to one of our Whistleblower Experts about what happened inside the practice. We build the case with you, bring in healthcare fraud whistleblower lawyers who understand orthopedic billing, and stay beside you through the pursuit of a recovery.