Primary Care Physicians settle false claims allegations for unsupported diagnoses to Medicare Advantage Program

May 25, 2023

A primary care group will settle with the Department of Justice (DOJ) for submitting unsupported diagnoses to the Medicare Advantage (MA) program.  Complete Physician Services (CPS) in Philadelphia will pay $1.5M plus interest to settle False Claims Act (FCA) violations for submitting unsupported diagnoses to the MA program.  “The FCA provides that any person who knowingly submits, or causes to submit, false claims to the government is liable for three times the government’s damages plus a penalty that is linked to inflation1  The MA program (Part C) is available to Medicare beneficiaries and bundles services that are covered under Medicare Part A (hospital/skilled nursing benefits), Part B (medical/outpatient benefits), and many times Part D (prescription benefits).  MA programs can also offer additional benefits not typically available through traditional Medicare.  MA reimbursement is based on the severity of the patient’s medical condition.  The more complex chronic condition the patient has, the higher the reimbursement.

“The government also alleges that CPS caused the submission of inappropriate claims to the Medicare Part B program that were not supported by medical documentation from January 1, 2015, to December 31, 2018, in order to maximize its reimbursement.”  CPS had:

  • Medically unsupported claims for morbid obesity (with a body mass index under 35)
  • Medically unsupported claims for chronic obstructive pulmonary disease (COPD)
  • Inadequate documentation to support the diagnosis submission of COPD
  • Inappropriately billed Evaluation & Management CPT code 99214 “without the requisite level and complex medical decision making that this code requires.”
  • Inappropriately billed “incident-to” services by the physician assistant including when the supervising physician was out of the country
  • Submitted unsupported claims for smoking cessation counseling, pulmonary function tests, and vaccine administration

Read the entire press release here:

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