Featured Article

Catching health care fraud with statistical graphics

Inflating codes that determine how much Medicare and Medicaid pay to health care providers is common practice among fraudsters. Now they’re doing it in increasingly sophisticated ways. Here we examine how statistical graphics can help spot upcoding in what can be an arcane and complicated billing process.

When Florida Governor Ron DeSantis banned all nonemergency medical procedures in the state in early 2020 to help battle rising COVID-19 cases, Physician Partners of America LLC (PPOA) searched for other ways to compensate for falling revenue. The solution? The health care provider allegedly required its physicians to schedule unnecessary telemedicine visits every 14 days instead of each month. It then overbilled Medicare and Medicaid, the U.S. federal insurance systems for older and low-income Americans, by submitting overvalued evaluation and management (E&M) codes that compensated PPOA more than was warranted by the patients’ visits.

PPOA’s alleged scams didn’t stop there. The U.S. Department of Justice (DOJ) accused it of submitting claims to Medicare for unnecessary urine drug testing and illegally incentivizing its physicians to order such tests by paying them a percentage of the revenue garnered from such illicit activity. And to top it off, PPOA also lied to the U.S. Small Business Administration about its illicit activity to obtain a $5.9 million loan from the Paycheck Protection Program. In April, PPOA’s founder, Rodolfo Gari, and its former chief medical officer, Dr. Abraham Rivera, agreed to pay $24.5 million to resolve those allegations. (See “PPOA Settlement Agreement,” Phillips and Cohen, March 23, 2022 and “Physician Partners of America to Pay $24.5 Million to Settle Allegations of Unnecessary Testing, Improper Remuneration to Physicians and a False Statement in Connection with COVID-19 Relief Funds,” DOJ, April 12, 2022.)

Medicare and Medicaid use codes like the ones in the above case to determine how much to pay insurers and health care providers. The agencies continue to be easy targets for fraudsters seeking to scam the state insurance system. Codes are used to categorize procedures, diagnoses and equipment. The billing system for these areas can seem complicated and arcane, which of course makes them vulnerable to fraud. The manipulation of diagnosis codes, for example, recently has been particularly prevalent, resulting in some large legal cases. (See “Everything you need to get started in medical billing & coding,” MB&CC and “Introduction to Billing Code Systems,” ASHA.)

For full access to story, members may sign in here.

Not a member? Click here to Join Now. Or Click here to sign up for a FREE TRIAL.