Visiting Physicians Association: Home Visits, Higher Codes, and the Same Patients

In the Visiting Physicians Association home health fraud settlement announced in 2009, the company agreed to pay $9.5 million over allegations of unnecessary services and inflated visit coding. The government alleged that VPA billed Medicare, TRICARE and Michigan Medicaid for unnecessary home visits, care-plan oversight, tests and procedures, and for more complex visits than it actually provided. If you know what happened in the patient’s home and what appeared on the bill, you know the difference at the center of this case.

The Justice Department’s announcement covered four qui tam lawsuits brought by whistleblowers. A separate case over in-home radiology testing ended in dismissal. Later, VPA and U.S. Medical Management reached another settlement over Medicare laboratory and diagnostic-testing payments.

VPA’s Home-Visit Business

Visiting Physicians Association was a Michigan professional corporation based in Farmington Hills. At various times, it provided home health services in Michigan, Ohio, Georgia and Wisconsin.

The government’s allegations reached both the reason for providing a service and the way the company billed it. It alleged that home visits and care-plan oversight were unnecessary, that tests and procedures were unnecessary, and that evaluation and management claims described services more complex than those actually delivered. That last allegation is visit upcoding: the description sent for payment outruns the work done for the patient.

For a physician, the clinical question might be why a patient needed another visit or test. For a coder, it might be whether the visit supported the level billed. For someone working with care plans, it might be what oversight the physician actually performed. Those are different observations inside the same business, and each can connect the clinical record to a payment demand.

Home-based care involves several sets of records. The certification and plan of care support the agency’s provision of skilled services. The agency assessment, treatment notes and claim capture other parts of that work. VPA’s settlement focused on the services and coding the government identified, including physician oversight and testing.

The Department of Health and Human Services Office of Inspector General, the FBI and the Michigan Attorney General’s Office investigated. The settlement addressed allegations of unnecessary services and inflated visit coding.

Four Whistleblowers, One Shared Reward

The four whistleblower plaintiffs were collectively allocated approximately $1.7 million under the settlement. The resolution covered four qui tam lawsuits brought by whistleblowers.

The Person Who Sees the Images and the Person Who Sees the Bill

A radiology contractor sees the images. A billing employee sees the claim. In the separate VPA radiology case, the court dismissed allegations about defective in-home studies because the whistleblowers had not sufficiently connected the tests to actual government claims.

Our work with healthcare insiders starts by connecting those views. A clinician’s account of a test and a billing employee’s account of the claim can concern the same encounter while answering different questions. We examine how they fit together, including what the company knew about the service when it sought payment.

The U.S. Medical Management and VPA Medicare Overpayment Settlement

U.S. Medical Management, LLC and VPA, P.C. agreed to pay $8.5 million in the resolution announced on October 8, 2021. The government alleged that the home-based health care providers submitted Medicare claims for laboratory and diagnostic tests that were not reasonable and necessary to diagnose or treat an illness or injury.

The tests covered by the resolution were performed from January 1, 2010 through December 31, 2015. The United States characterized the Medicare payments for those claims as overpayments.

The agreement resolved allegations raised in five whistleblower lawsuits. The Justice Department said a whistleblower would receive $1.53 million from the settlement.

The Complaint’s Account of Patients, Therapy and Coding

One of the complaints identified in the later settlement came from the administrator of Phoenix Home Health Care. It alleged that the defendants acquired Phoenix to move VPA-controlled patients there from Family Nurse Care. The complaint described those patients receiving therapy first through Family Nurse Care and then through Phoenix.

Patients Moved From One Agency to Another

The complaint alleged that the defendants sought control of Phoenix to move VPA-controlled patients out of Family Nurse Care and reduce scrutiny. It described the purpose directly:

According to the complaint, revenues that had gone to Family Nurse Care could then go to Phoenix, creating the appearance that the former agency’s regulatory problems had been corrected. It alleged that Family Nurse Care had not complied with the government’s request for corrective action.

New agency. Same patients.

We see the alleged sleight of hand in what moved with them. The complaint said the defendants intended to transfer patients whose care records were inadequate and, in some cases, repeat therapy that had already been provided. The alleged change moved the patients and revenue to another agency while carrying the underlying care concerns with them.

Therapists Objected to Repeated Treatment

The administrator’s account alleged that a Florida-based VPA physician prescribed repeated courses of a physical therapy program called Optimum Balance based solely on records reviews. Patients received the program through Family Nurse Care and then Phoenix, even though the therapists responsible for administering it strongly believed the treatment was unnecessary.

Therapists moved from Family Nurse Care to Phoenix allegedly recognized patients who had just been discharged from the former agency. They reported that some had already received the same regimen three or four times. The allegation about unnecessary home health care therefore involved the people delivering therapy challenging the clinical need for repeating it.

That is the part an employee may recognize before a claim reviewer does: the same patient, the same course of treatment, and a new agency receiving the patient. The complaint joined those observations to the alleged transfer of revenue. We would examine the treatment history, the therapist’s assessment and the prescribing decision together to understand why the next course was ordered and billed.

A Review of the Records and a Change in Coding Instructions

The complaint alleged that a May 2007 report from home health consultant McBee & Associates found only 13% of the Family Nurse Care records it reviewed met all Medicare coverage criteria and billing compliance. It also recounted another set of whistleblowers’ allegations about VPA’s evaluation and management billing. According to that account, Medicare inquiries in August 2005 prompted an abrupt change in instructions to physician employees. The recounted policy had been to bill 90% of visits as comprehensive exams. The complaint quoted the replacement instruction:

We see a billing target in that alleged instruction, where the patient’s needs should decide the service. We would compare it with what physicians actually did during those visits and with the claims submitted before and after the change.

The Alleged Business Excuse

The filing also recounted a physician’s allegation about the explanation offered by VPA executives. According to that account, they defended the alleged fraudulent activities as common practice, applicable to all patients, and necessary to keep the company afloat and pay employees’ salaries.

We see a business survival argument in that account. It asks employees to accept the alleged conduct as the price of keeping the operation going. Calling an activity common practice offers an explanation of the pressure inside a business. It does nothing to answer the patient or taxpayer paying for it.

For an insider, that alleged response matters alongside the billing instruction. One describes what employees were told to do. The other describes how management allegedly justified the conduct. We would examine the direction, the objection and the response together with the affected claims. The question is who knew what was being billed and how they defended it when challenged.

Physician Oversight Has Its Own Billing Evidence

A separate case involving Docs at the Door shows how specific oversight evidence can become. False care-plan-oversight logs claimed 30 minutes of monthly physician supervision that had not been performed. In his guilty plea, the physician owner admitted the broader scheme, and the civil court relied on those admissions and the unrebutted facts when it entered judgment against him and the company in March 2023.

The practical connection to VPA is the oversight claim itself. A log represents work by a physician. The clinical record, the person who entered the work and the claim submitted for it can reveal whether that representation matches what happened. VPA’s settlement resolved allegations of unnecessary oversight. The Docs at the Door judgment concerned oversight never performed.

What Evidence Is Needed to Prove Fraud?

We work with insiders to connect the service’s clinical basis, what actually happened, the description billed and the government’s payment. We investigate the decisions behind those records.

For a comprehensive-exam claim, we compare the visit with any corporate instruction about how to code it. For repeated therapy, we examine the patient’s treatment history alongside the assessment of the people delivering it. The company may describe a service one way while its own employees describe something quite different.

On the agency side, assessment answers that affect payment add another connection. OASIS is part of the comprehensive assessment, and its data feed payment grouping alongside claim information. The agency’s assessment, care plan, visit documentation and remittance can sit with different people. That is why we examine the path between them when assessing an insider’s account.

You may know the clinical work, the billing instructions or the agency transfer. We bring those details together around the particular service and payment, with home health fraud whistleblower lawyers who understand the relevant claims. The case begins with what your position lets you see.

How Much Does Medicare Fraud Whistleblower Pay?

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. We build the case with you, connecting what you saw in the patient’s home to the decisions behind the billing.

You Know the Visit Behind the Bill

If a visit, test or oversight charge tells a different story from the care you saw, speak with our whistleblower experts about the billing. We build your account into a focused case, bring in home health fraud whistleblower lawyers who know physician-service billing, and stay beside you through the decisions that follow.