The False
Claims Act was used to resolve billing allegations of upcoding. Two related dermatology and cosmetic medical entities, Rhode
Island Dermatology and Cosmetic Center, LLC, and Rhode Island Dermatology OBS,
LLC recently paid $152,043.25 to resolve civil allegations that they violated
the federal False Claims Act by billing Medicare for some patient services and
procedures performed at rates higher than were warranted.
The
investigation was conducted by the U.S. Department of Health and Human
Services, Office of Inspector General (HHS-OIG) and the United States
Attorney’s Office. The United States alleged that between 2009 and 2014, Rhode
Island Dermatology, which provides dermatology, plastic surgery, and cosmetic
surgery services, billed Medicare for surgical closure procedures at a higher
rate of complexity than was supported by certain patients’ condition or the
circumstances of the closure, and which should properly have been classified at
a lower billing rate for less complex procedures.
In general, the amount that Medicare pays for a given medical or surgical procedure is frequently dependent on the complexity of that procedure. Upcoding, or billing for a level of complexity that is not warranted by a patient’s actual condition and treatment, results in improperly higher payments for care that should have actually been reimbursed by Medicare at a lower rate.
In
this case, the matter was settled prior to litigation on or about November 8,
2015, without an admission of liability or wrongdoing on the part of the
practice. The settlement amount for billings over a five year period and the
lack of admissions demonstrate that this was not a criminal case and it appears
the medical practice had mounted a strong defense in order to obtain this
favorable settlement.
Posted by Tracy Green, Esq.
