“Incident To” Fraud Claims

Doctors cannot charge full “physician rates” for medical services by non-physicians unless the services are “incident to” what the doctor does and if the doctor supervises the treatment. The False Claims Act (FCA) gives whistleblowers a way to file a lawsuit to report “incident to” and “lack of supervision” fraud. The whistleblower can help save taxpayer money and can receive from 15% up to 30% of the amount that the Government recovers thanks to the whistleblower.

Do you know about a doctor who is telling Medicare or Medicaid that he is supervising treatment by a non-physician — even though he really is not? You can do something to stop the fraud and hold the doctor accountable by calling The Wallace Law Firm, LLC. Speak with Lee Wallace, an experienced Atlanta Medicare/Medicaid fraud lawyer who has won millions of dollars for clients in whistleblower cases.

Free consultations are available. Just call (404) 550-4615.

How Medical Providers Defraud Medicare & Medicaid

Medicare and Medicaid have agreed to reimburse doctors a certain amount when they treat patients.

Medicare and Medicaid also will reimburse doctors and hospitals when patients are treated by:

  • Physician’s assistants
  • Nurse practitioners
  • Clinical nurse specialists
  • And other non-physician providers (NPPs) treat patients.

When the services performed by the NPP are “incident to” the physician’s services, and directly supervised by the physician, the physician can bill the treatment at 100% of the rate under the physician fee schedule. However, if the treatment is not “incident to” what the physician does, or is not directly supervised by the doctor, then Medicare and Medicaid will reimburse the treatment at a lower rate, typically 85% of what it would have paid had the doctor rendered the services personally.

In order to game the system, some practices and physicians let NPPs treat patients, but then pretend that all of the treatment was provided by a medical doctor. Instead of upcoding the procedure, essentially the group is upcoding the provider in order to get a higher level of reimbursement. Medicare, Medicaid And TRICARE Consider This Practice To Be Fraudulent.

When Medicare Will Not Accept a Doctor’s Claim That NPP Services Were “Incident To” His Care For A Patient

  • A New Jersey physiatrist stood accused of submitting claims for medical services that supposedly were “incident to” his care for patients. According to the Office of Inspector General, however, the physiatrist was not directly supervising the work, and in fact was not even in the State where the patients were being treated. The doctor paid the Government $1,500,000 to resolve the allegations that he had overcharged the Government for treatments given to patients covered under government programs.
  • Sometimes medical providers take the matter so far that they reach the level of the absurd. For example, several doctors have been caught claiming they performed more than 24 hours’ worth of services in a single day. Obviously Medicare, Medicaid — and the Department of Justice — can clearly see that the services were not and could not all have been rendered by the physician.
  • The Government is very unlikely to believe that an NPP’s services are “incident to” a physician’s treatment if the physician who supposedly is treating the patient — like the New Jersey physiatrist — is not even in the office where the patient is being treated.

Medicare and Medicaid are stretched to the breaking point financially; they can ill-afford to lose money to fraud. If a physician is overcharging for services by pretending he is personally performing or supervising them — when he is not — then a whistleblower has the chance to stop the fraud and regain money the taxpayers are losing. The FCA gives whistleblowers a chance to stop fraud and be rewarded based on what the Government recovers.

Discuss Your Case with an Atlanta “Incident To” Fraud Attorney

If a doctor is falsely claiming he is supervising non-physicians for services “incident to” what he himself is providing, take action by calling The Wallace Law Firm, LLC today. Lee Wallace is eager to put her 25 years of experience to work for whistleblowers filing lawsuits under the False Claims Act and Stark Act.

You can reach our team at (404) 550-4615 if you have questions about your case.