CareWell Urgent Care Center Agrees to Pay $2 Million to Resolve Allegations of False Billing of Government Health Care Programs
BOSTON – The United States Attorney’s Office announced today that CareWell Urgent Care Centers of MA, P.C., CareWell Urgent Care of Rhode Island, P.C., and Urgent Care Centers of New England Inc. (CareWell), the owners and operators of urgent care centers located throughout Massachusetts and Rhode Island, have agreed to pay $2 million to resolve allegations that they violated the False Claims Act by submitting inflated and upcoded claims to Medicare, Massachusetts Medicaid (MassHealth), the Massachusetts Group Insurance Commission (GIC), and Rhode Island Medicaid.
Urgent care centers receive payment for Evaluation and Management (E/M) services by submitting Current Procedural Terminology (CPT) codes which reflect the level of E/M service performed. The level of E/M service is determined, in part, by the number of 14 possible body systems (e.g. cardiovascular, gastrointestinal, neurological, etc.) a physician, nurse practitioner, or other medical professional must review and examine to diagnose and treat a patient’s specific medical complaints. Generally, the more complex a patient’s medical complaints are, the more body systems may need to be reviewed, reflecting a higher level of E/M service performed. Urgent care centers are required to submit CPT codes for E/M services that are reasonable and medically necessary for an urgent care center to perform in light of the history of, examination into, and medical decision-making required for a patient’s medical complaints. In addition, urgent care centers must submit claims that properly identify whether a nurse practitioner, without the direct supervision of a physician, performed the E/M service in order to accurately determine the amount of payment they should receive.
The United States, the Commonwealth of Massachusetts, and the state of Rhode Island allege that, between March 1, 2013, and August 31, 2018, CareWell submitted false claims to Medicare, MassHealth, GIC, and Rhode Island Medicaid by falsely inflating the level of E/M services performed and by failing to properly identify the providers of E/M services. The governments contend that CareWell accomplished its fraud in several ways, including mandating that medical personnel examine and document at least 13 body systems during medical history inquiries, and at least nine body systems during physical examinations, even if patients’ specific medical complaints or symptoms did not justify such a comprehensive inquiry or examination.
CareWell instructed medical personnel to use encounter plan templates, loaded onto electronic medical records software, containing “yes or no” questions that CareWell directed its personnel to ask patients regarding specific body systems, even when such inquiries were not medically necessary. Even if medical personnel failed to ask a patient every question in an encounter plan template, the template contained a default “no” response to each inquiry. CareWell used the default “no” responses to assert that the associated body systems had been examined and billed accordingly, even when no such examination had occurred. The governments also allege that CareWell’s management told its medical personnel that the mandate of examining body systems unrelated to a patient’s specific medical complaints or symptoms was a requirement imposed by a malpractice insurance carrier, even though CareWell knew that no malpractice insurance carrier had ever imposed such a requirement on CareWell. In addition, the governments contend that CareWell failed to reduce the amounts of its claims to Medicare, MassHealth, GIC, and Rhode Island Medicaid for services performed by unsupervised nurse practitioners.
“The CareWell urgent care centers engaged in a calculated scheme to reap unjustified economic benefit for their own gain from precious government healthcare resources,” said United States Attorney Andrew E. Lelling. “Today’s result reinforces this office’s commitment to take action against providers that have defrauded government healthcare programs.”
“Inflating bills and submitting claims to government health insurance programs for needless services drains resources from legitimate patient care,” said Phillip Coyne, Special Agent in Charge, Office of Inspector General of the U.S. Department of Health and Human Services. “Those seeking to enrich themselves at the expense of these taxpayer-funded programs must be held accountable.”
This civil settlement resolves allegations brought forth in a whistleblower lawsuit filed by a former employee of CareWell, Aileen Cartier, under the qui tam provisions of the False Claims Act, which permits private individuals, known as relators, to sue on behalf of the government for false claims and to share in any recovery. In connection with today’s announced settlement, Ms. Cartier will receive 17 percent of the recovery.
U.S. Attorney Lelling and HHS-OIG SAC Coyne made the announcement today. This case was handled by Assistant U.S. Attorney Steven Sharobem of Lelling’s Civil Division, Assistant Attorneys General Cassandra Arriaza, Jennifer Goldstein, and Ali Russo from the Massachusetts’ Attorney General’s Office and Assistant Attorney General James Dube of the Rhode Island’s Attorney General’s Office.