Qui tam False Claims allegations cost Maryland medical center more than $3 million

Anne Arundel Medical Center (AAMC) in Annapolis, Maryland, will pay $3,154,000 to settle allegations that it submitted false claims to Medicare for medically unnecessary evaluation and management (E/M) services and separately billing bundled procedures, according to the Department of Justice (DOJ).

In 2007, AAMC opened the Anticoagulation Clinic, an outpatient clinic focused on monitoring patients on anticoagulation therapy by performing routine prothrombin time international normalized ration (PT-INR) tests. A PT-INR test measures how long it takes for a patient’s blood to clot and may be billed with CPT® code 85610 (prothrombin time).

If the test indicates that the patient’s medication needs to be adjusted, or if the patient presents with a change in medical condition, the practitioner may perform and bill for an E/M service. From 2010–2013, AAMC submitted false claims for medically unnecessary E/M services at the same time it submitted claims for PT-INR tests, according to the DOJ.

Additionally, starting in 2014 CMS bundled PT-INR tests with E/M services if both services are provided during the same visit. The bundled services are billed using HCPCS code G0463. From 2014–2017, AAMC submitted claims for G0463 and for 85610 when both services were provided on the same day, essentially double billing for PT-INR tests.

Along with the civil settlement, AAMC entered into a five-year corporate integrity agreement (CIA). The CIA requires AAMC to implement a risk assessment and internal review process as well as training, auditing, and monitoring.

The allegations against AAMC were raised by former AAMC employee Barbara McHenry under the qui tam provisions of the False Claims Act. Qui tam allows people with evidence of fraud against federal programs or contracts to sue the wrongdoer on behalf of the federal government. The whistleblower can then share in any recovery as a result of action against the wrongdoer. McHenry, a clinical pharmacist, was assigned to AAMC’s Anticoagulation Clinic in 2007. In 2011, McHenry was promoted to supervisor of the clinic. According to her lawsuit, McHenry subsequently notified upper management that the clinic was overbilling Medicare. Her complaint was ignored and she was fired in 2014, the Capital Gazette reported. McHenry will receive $473,100.