April 10, 2019
The United States Department of Justice (“DOJ”) issued a press release regarding a recent $2 Million settlement related to allegations that a provider violated the False Claims Act by submitting inflated and upcoded evaluation and management (“E/M”) claims to Medicare and Medicaid, over a five year period. The DOJ alleged that the provider inflated and upcoded E/M claims by setting the default answer to “no” on the electronic medical record, when an examination was not conducted.
The provider and its related entities (“CareWell”), own and operate urgent care centers in Massachusetts and Rhode Island. E/M services are billed and paid at urgent care centers based on the level of E/M service performed and number of body systems reviewed. Generally, the more complex the patient, the more body systems reviewed, the higher level of E/M service performed, the higher the payment amount.
The DOJ alleged that CareWell submitted false claims for E/M claims by:
The settlement is the result of allegations brought in a whistleblower lawsuit filed by a former employee, under the qui tam provisions of the False Claims Act. A copy of the press release is available at the following website: https://www.justice.gov/usao-ma/pr/carewell-urgent-care-center-agrees-pay-2-million-resolve-allegations-false-billing
These allegations and resulting settlement underscore the importance of reviewing electronic medical record templates and ensuring that all responses, whether actively selected or set by default, properly reflect the services performed and do not automatically create the implication that a service was performed when it actually was not.