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$2 Million Settlement Highlights Coding and Billing Fraud Problems

Posted by David Fong on May 29, 2019 11:05:18 AM

The United States Attorney’s Office District of Massachusetts recently announced that CareWell Urgent Care Centers2MM settlement has agreed to pay $2 million to resolve allegations they violated the False Claims Act by submitting claims to Medicare, MassHealth, GIC, and Rhode Island Medicaid that falsely inflated the level of E/M services performed and by failing to properly identify the providers of E/M services.


This recent settlement highlights the need for improved coding practices and the problems of coding and billing-related fraud. The governmental bodies bringing the claims against CareWell alleged the company pushed providers to examine patient body systems in comprehensive ways that weren’t justified by the patient’s condition. By instructing medical staff to conduct questionnaires for patients with “yes/no” questions even if the line of questioning was not medically necessary, it allegedly created a structure where examinations appeared to be completed, when in fact they might not have occurred at all.


The Evaluation and Management (E/M) services at the center of the fraud are determined by the Procedural Terminology (CPT) codes. These codes are delineated by various body systems that a practitioner must review in order to determine the patient’s likely condition and course of treatment. Urgent care centers, like all providers, must submit these codes for services that are determined to be necessary for treatment, and then present claims that truthfully reflect those services, including the type of person (nurse practitioner or doctor, etc.) that administered the care.


The allegations against providers like CareWell underscore the need for diligence in coding procedures.  Named by Modern Healthcare as one of the top ten largest revenue cycle management firms, Aviacode gives providers of all sizes the opportunity to avoid unintentional or fraud-based errors. A core strength of Aviacode is its experienced AAPC or AHIMA certified coders who specialize in an assortment of more than 60 medical specialties and accurately code more than 10 million encounters per year.

Topics: Medical Coding, CPT code