WNY Medical: Chronic Care Management Claims Without the Required Staff Time

In the WNY Medical chronic care management settlement, the practice agreed to pay $251,477 to resolve allegations that it billed Medicare without providing the required clinical-staff time. For a nurse, care coordinator or billing employee who knows how a monthly total became a claim, the case turns on a familiar question: who actually did the work?

Western New York Medical P.C. operated health care locations in Erie and Niagara Counties. The Justice Department announced the settlement on February 19, 2025.

The Missing Work Was Monthly Clinical-Staff Time

The government alleged that, from January 1, 2020 through March 31, 2023, WNY Medical billed Medicare for chronic care management encounters without supplying at least 20 minutes of clinical-staff services during the billed month for a portion of those encounters. The U.S. Attorney’s Office for the Western District of New York and the U.S. Department of Health and Human Services Office of Inspector General coordinated the resolution.

The CMS booklet describes code 99490 as covering the first 20 minutes of qualifying clinical-staff time per month. A qualifying patient and a completed month of care answer different questions. We examine how the practice connected the patient, the staff member and the activity to the billed month.

What a Monthly Chronic Care Management Claim Pays For

Chronic care management ties payment to qualifying patients, specified work and the person performing it. The CMS chronic care management booklet from June 2025 describes patients with at least two qualifying chronic conditions expected to persist for at least 12 months or until death and to pose significant risk.

The code identifies whose time the practice is selling. Code 99490 covers the first qualifying clinical-staff minutes in the month. Practitioner chronic care management under code 99491 instead requires 30 minutes personally furnished by a physician or other qualified professional.

For an insider, those distinctions explain why a monthly total needs a worker and an activity behind it. A physician’s name on a claim does not tell us who performed the service, and a care plan describes a different part of the care than the time spent carrying it out. We line up who did the work, what they did and the month it was billed.

Chronic care management also limits how a practice can use the work it records. Clinical-staff time cannot stand in for a practitioner’s personal time, and the same minutes cannot support duplicate care-management claims. Only one practitioner may bill a beneficiary’s monthly care-management service. For an employee who sees several services on the same account, the distinction is concrete: which activity belongs to the care-management claim, and which belongs to another service? We follow that connection because a total detached from its underlying activity hides what Medicare was asked to buy.

What Evidence Does a Whistleblower Need?

For a missing-time allegation, useful evidence connects the claim to the underlying work: the patient, the billed month, the worker’s role, the activity and the time attributed to it. We compare the practice’s billing account with its clinical documentation and the account of someone who understands how those entries were made.

The 2017 Journal of AHIMA article Busting Bad Medicine: A Call to Action Addressing Healthcare, Fraud, Waste, and Abuse describes checking treatment dates, treatment types and nurse or physician signatures. Its point about witnesses explains why an insider’s knowledge can add something the entries alone cannot:

A care coordinator may understand the activity recorded against the patient. A billing employee may understand how that activity became a charge. Someone responsible for reviewing the totals may know which discrepancies reached management and how the practice responded. Those perspectives help us connect the care, the claim and the decisions behind it.

Who Reviewed the Billing?

The person checking a practice’s billing may also be responsible for producing it. Implementing a Physician Practice Compliance Program, a chapter in Health Care Administration: Managing Organized Delivery Systems, published by Jones and Bartlett in 2011, describes the independence problem: an office manager or billing supervisor can end up reviewing their own work and the physician’s billing. The chapter also questions whether oversight by the physician solves that problem, since the records and bills being reviewed are the physician’s own.

The chapter describes reviews that bring together medical records, billing-system reports, computer records and staff interviews. It also connects findings to changes in internal controls and staff education. Applied to monthly care-management billing, that means we examine how the total was checked and what happened when the underlying activity failed to support it. An employee who knows the review process may be able to explain why an unsupported charge kept reaching Medicare.

Bluestone’s Alleged Overbilling for Visits and Monthly Care

Bluestone Physician Services agreed to a $14,902,000 settlement over allegations involving chronic care management and domiciliary rest home visits. In its June 5, 2024 announcement, the Justice Department described claims that allegedly lacked the level of services represented under Medicare, Medicaid and TRICARE requirements. A former general manager for Bluestone’s Florida market brought the whistleblower case.

Bluestone’s allegations involved visit code 99337 and monthly chronic care management code 99490. The parallel is the gap between the care represented on a claim and the care delivered. For someone who knows the practice’s billing, we examine each charge against its own work requirement, including whether the monthly service had distinct work behind it.

How Much of a Recovery Does a Whistleblower Get?

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. The whistleblower reward follows the government’s recovery, so our work with you focuses on connecting the practice’s decisions to the claims and the money paid for them.

The Person Behind the Monthly Total

If you know why a practice billed for care-management time its staff never supplied, tell our whistleblower experts how the billing worked. We use that inside knowledge to build your strongest chronic care management whistleblower case and bring in healthcare fraud whistleblower lawyers who understand monthly Medicare billing. You have a partner from the first conversation through the pursuit of a recovery.