USMM and Visiting Physicians Association: Home-Based Testing and Overpayment

In the USMM VPA laboratory settlement, U.S. Medical Management and Visiting Physicians Association agreed to pay $8.5 million to resolve allegations of medically unnecessary laboratory and diagnostic testing billed to Medicare. The providers delivered home-based health care services. For someone inside that business, the case reaches across the visit, the clinical reason for the testing, and the claim Medicare paid. The government’s central contention was that the services did not meet the standard for diagnosis or treatment of an illness or injury.

What USMM and VPA Billed Medicare

USMM and VPA billed Medicare for laboratory and diagnostic services performed from January 1, 2010 through December 31, 2015, according to the Justice Department’s October 8, 2021 announcement. It identified the providers as U.S. Medical Management, or USMM, and VPA, the professional corporation doing business as Visiting Physicians Association.

The government alleged that the services were not reasonable and necessary for diagnosis or treatment. It described the money USMM and VPA received on those claims as overpayments: Medicare had reimbursed services the government said were not eligible for payment. Taxpayers had funded testing the government said patients did not need.

For an insider, the useful connection is between what the patient needed, what the provider ordered and what the company charged to the program.

Why the Home-Based Provider Matters

The treating practitioner holds a crucial part of the testing story: why the patient needs the test and how its result bears on care. Under Medicare’s diagnostic testing rules, the treating physician generally orders the test and uses the result to manage the patient’s medical problem.

USMM and VPA, the providers delivering home-based care, billed Medicare for the laboratory and diagnostic testing themselves.

VPA’s Earlier Settlement Covered Visits as Well as Tests

Visiting Physicians Association had a separate $9.5 million settlement, announced on December 23, 2009, over allegations of unnecessary home visits, tests and other services billed to Medicare, TRICARE and Michigan Medicaid.

Five Whistleblower Suits and a Share of the Settlement

The USMM/VPA resolution addressed allegations raised in five qui tam cases under the False Claims Act. The government did not join those cases, but it still reached a settlement with the companies over Medicare’s payments.

The Justice Department announced a $1.53 million payment to a whistleblower from the settlement.

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

You Know What the Visit Was For

If you know how home visits became testing orders and Medicare claims, speak with our whistleblower experts about what you saw. We build your case around the clinical and billing decisions you can explain and bring in healthcare whistleblower lawyers who know laboratory testing and Medicare reimbursement. Our experts stay beside you from the first account of the visits through the pursuit of a recovery.