United States Attorney Jacqueline C. Romero announced that Complete Physician Services, Kenneth Wiseman, DO, and Steven Schmidt, DO (collectively, “CPS”), have agreed to pay a total of $1,500,000 plus interest to resolve False Claims Act allegations that they caused the submission of false claims by misrepresenting the severity of illness and services rendered to increase reimbursement from the Medicare Part C (Medicare Advantage) and Part B programs. CPS, a primary care physician practice located in Philadelphia, treated patients under the Medicare Advantage program and the Medicare Part B (Medical Insurance) program.
The government alleges that CPS caused the submission of false claims for payment to Part C from January 1, 2015, to December 31, 2018, arising from CPS submitting unsupported diagnosis codes, resulting in increased reimbursement to Part C health insurance companies. Specifically, CPS submitted morbid obesity diagnosis codes to Part C where the diagnoses lacked medical support in that patients had a body mass index under 35. The government contends that the diagnosis of morbid obesity in this situation is inappropriate. Further, the government alleges that CPS’s submission of chronic obstructive pulmonary disease (“COPD”) diagnoses were not medically supported or supported by appropriate medical documentation in many instances. As a result of these unsupported diagnoses, CPS substantially increased Part C reimbursement from the Centers for Medicare & Medicaid Services (“CMS”).
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. Specifically, the government contends that CPS improperly billed Evaluation and Management visits using Current Procedural Terminology Code 99214 without the requisite level and complex medical decision making that this code requires. Further, CPS inappropriately billed physician assistant services “incident to” the professional services of a physician including occasions when the physician was out of the country. Finally, CPS also submitted unsupported billing to CMS for smoking cessation counseling, pulmonary function tests, and unsupported claims for vaccine administration.
