Whistleblower suit: Georgia cancer center 'systematically' upcoding
The administrative director of a Columbus, Ga., cancer clinic has filed a whistleblower lawsuit, alleging violations of the False Claims Act for "systematically" overbilling Medicare, Medicaid and TRICARE with widespread upcoding and shoddy documentation practices.
The John B. Amos Cancer Center, a part of the Columbus Regional Healthcare System, had a "complete lack of oversight" for medical oncologists' coding practices that "allowed it to systematically overbill Medicare and other federally funded health benefit programs for years, reaping potentially millions of dollars in unearned fees," said the legal complaint filed on behalf of Richard Barker, who joined the center in September 2011 as administrative director.
The recently-unsealed 65-page complaint drops much of the blame on the fact that medical oncologists at the center, paid with relative value unit methodology after three years, "are given responsibility to code their own work." That creates "a direct correlation between a medical oncologist's compensation and the billing code he or she chooses to seek reimbursement from third party payers," the lawsuit alleges.
Barker, who previously worked as compliance office for Cancer Care Partners in Mishawaka, Ind., first noticed what he thought were improper coding and billing practices almost immediately after joining the John B. Amos Cancer Center, which is named after the founder of the supplemental insurance company Aflac.
Barker looked into the issues and, according to the complaint, identified billing for office visits "at levels that were not supported by the documentation" and billing for evaluation and management services that "were included for the administration of chemotherapy and thus were not separately billable."
Barker concluded that these problems "were widespread" -- and that they violated Centers for Medicare & Medicaid policy requiring that CPT codes appropriately reflect the "medical necessity" of the office visit, that they be supported by medical records, and that the documentation in the medical records be completed during or soon after a patient visit, the complaint alleges.
The medical coders at the cancer center took the codes submitted by oncologists without having the medical records to verify the codes' accuracy before billing submission -- and that documentation "may, in fact, not exist," the complaint alleges.
The John B. Amos Cancer Center does not use electronic medical records, according to the complaint, and instead of digital documentation, "physicians may complete their medical documentation by dictating their impressions of their encounters with patients into cassette records," with the notes then transcribed and
returned before being reviewed, signed and placed into a patient's chart.
"Under this system, many patient records are not transcribed for up to six months after the patient visit -- long after the claim form has been submitted for the patient encounter," the complaint said.
Shortly after he started working, Barker was shown a bookcase of the cancer center's medical director, Andrew Pippas, MD, holding patient medical records that contained unsigned physician orders for drugs and laboratory tests, missing dictation and patient encounter forms with "HNO," for hand note only, written on them, according to the complaint.
After reviewing them, Barker found that "many, if not most of these HNO encounter forms did not contain enough information to support the CPT charge indicated for that day's visit."
Barker raised these issues in October 2011 meetings with his boss, Kevin Sass, the CEO of the Doctors Hospital, a sister provider in Columbus Regional Healthcare System, and pointed in particular to Pippas for allegedly generating a "disproportionate number" of visits with CPT codes at level 5 -- valued at $159.30, compared to $99 for code level 4.
Those level 5 codes, Barker told Sass, could look suspicious to auditors for CMS or other insurers. Sass, who left the health system last February, "agreed and admitted that this was not the first time that he had heard of this issue," according to the complaint.
Later in October 2011, Barker learned, according to the complaint, the cancer center's interim patient financial services associate director emailed Susan Norton, the center's director of self pay, writing that there were "in excess of 200 charts in Dr. Pippas' office that have not had dictation done on that we have already charged and billed for."
Norton forwarded that email to Roland Thacker, the Columbia Regional Healthcare System's CFO, along with Sass and other leaders in the health system, according to the complaint, and in November of 2011 told them that there was no improvement in dictation and chart completion and that there were employee concerns about "billing and collecting with incomplete patient records."
Several months later, in January 2012, according to the complaint, Thacker told Norton that Jeffrey Johnson, professional fees director at the cancer center, had done a brief audit and recommended that "all professional billings should be suspended until documentation or chart is considered complete."
The cancer center eventually hired a third party auditor, Health Management Resources, which in July 2012 confirmed some of Barker's suspicions, according to the complaint. The firm reviewed 40 charts, and for Wilbur Bassett Jr., MD, one of the center's five oncologists, found an over-coding rate for evaluations and management (E&M) of 63 percent -- much higher than the 10.5 percent error rate CMS considers acceptable for E&M services.
That, while the health system's internal audit found no over-coding rates for E&M services performed by Bassett, the complaint alleges.
The third party auditor found an E&M upcoding rate for Pippas, the center's medical director, of 68 percent -- which, coupled with no findings of under-coding, "is consistent with fraud and inconsistent with a finding of good faith errors or mistakes," the complaint alleges.
The Columbus Regional Healthcare System is declining to comment on the allegations, pending the litigation, senior VP of public relations Frank Austin said in a statement.
But with the allegations being publicized by the media in greater Columbus, Austin noted in the statement that "this legal action is focused on complex and very technical billing rules, not on matters related to quality of care."
Austin also said that "an error rate of zero simply is not achievable," and that "inaccurate billing is in part due to the voluminous regulations for Medicare and Medicaid reimbursements and in part due to differing professional opinions of the care rendered and how that is documented."
Suing the health system and the cancer center under the False Claims Act for the federal government, Barker, who has been placed on leave with pay, stands to earn up to 30 percent of any money that may be recouped. Barker's attorneys told the Columbus Ledger-Enquirer that the financial impact of the lawsuit, if the allegations are proven, could reach $100 million.
The lawsuit also alleges that the Columbus Regional Healthcare System violated the Stark and Anti-Kickback laws when it acquired the Tidwell Cancer Treatment Center in 2010 for $10.5 million.
The intention, the complaint alleges, was to secure referrals from the treatment center, later renamed Radiation Oncology of Columbus, with an agreement that it would have exclusivity in providing radiation oncology services.
