A Memphis doctor is facing charges of TennCare fraud and theft of property following an investigation by special agents with the Medicaid Fraud Control Division (MFCD) of the Tennessee Bureau of Investigation (TBI).
In February 2023, TBI’s MFCD agents received a fraud referral from the TennCare Office of Program Integrity. The referral alleged that the doctor had engaged in unbundling medical codes and excessively billed for certain procedures. Unbundling occurs when a provider uses multiple procedural codes that should be covered by a single comprehensive code in order to increase reimbursement.
The investigation revealed that between January 2018 and November 2022, the doctor submitted claims to TennCare that resulted in a loss of thousands of dollars to the State of Tennessee.
In March 2025, a Shelby County Grand Jury returned an indictment, charging the doctor with one count each of TennCare Fraud ($10,000–$60,000) and Theft of Property ($10,000–$60,000). The doctor was apprehended on March 13 and booked into the Shelby County Jail with a $35,000 bond.
Compliance Perspective
Issue
Accurate billing and coding are essential for preventing financial losses and legal risks in healthcare. Ensuring that claims are properly submitted helps avoid potential issues with fraud or mistakes in reimbursement. It is illegal to submit claims for payment to Medicare or Medicaid that you know or should know are false or fraudulent. Filing false claims may result in fines of up to three times the programs’ loss plus $11,000 per claim filed. Under the civil False Claims Act, each instance of an item or a service billed to Medicare or Medicaid counts as a claim, so fines can add up quickly. Facility staff should be knowledgeable in how to report suspicious billing practices. A nonretaliatory environment for reporting suspicious billing practices is mandatory for all facilities.
Discussion Points
- Review your policies and procedures for accurate billing that is supported by documentation detailing provision of services. Ensure services provided, supporting documentation, and billing codes match before claims are submitted.
- Train appropriate staff on how to determine each resident’s level of care and if services provided are reasonable and necessary.
- Periodically perform audits on claims before they are submitted to Medicare and Medicaid to ensure that the services being billed are necessary, accurate, and that there are no inconsistencies. Staff should be aware of compliance and ethics concerns and understand their responsibility to report any violations to their supervisor, the compliance and ethics officer, or via the anonymous hotline.
*This news alert has been prepared by Med-Net Concepts, Inc. for informational purposes only and is not intended to provide legal advice.*
