IMPROPER TEST UNBUNDLING: A Texas physician and her spouse have paid $430,000 to settle allegations they submitted false claims to Tricare, Medicare, and Medicaid for certain laboratory tests, according to U.S. Attorney for the Western District of Texas Robert Pitman. The settlement resolved allegations that Dr. Bola Elemuren, a family practitioner doing business as the Family Medical Clinic in Harker Heights, and her husband and office manager, John Ogunmuyiwa, knowingly overcharged Tricare for automated gynecology-related laboratory tests from 2003 to 2008. The test is a single procedure that must be billed under an inclusive billing code at a predetermined rate, Pitman said in a statement. The defendants “unbundled” and inflated their charges by separately billing the test under multiple current procedural terminology codes at a higher total cost to Tricare, prosecutors asserted. The unbundled claims made it appear as if the clinic performed more than one test and therefore was entitled to more than one payment from the government. The case was settled out of court following an investigation by the Department of Defense Criminal Investigative Service, Pitman said. He said the settlement agreement was not an admission of liability by Elemuren, Ogunmuyiwa, or Family Medicine Clinic. RAC APPEALS USUALLY […]
IMPROPER TEST UNBUNDLING: A Texas physician and her spouse have paid $430,000 to settle allegations they submitted false claims to Tricare, Medicare, and Medicaid for certain laboratory tests, according to U.S. Attorney for the Western District of Texas Robert Pitman. The settlement resolved allegations that Dr. Bola Elemuren, a family practitioner doing business as the Family Medical Clinic in Harker Heights, and her husband and office manager, John Ogunmuyiwa, knowingly overcharged Tricare for automated gynecology-related laboratory tests from 2003 to 2008. The test is a single procedure that must be billed under an inclusive billing code at a predetermined rate, Pitman said in a statement. The defendants “unbundled” and inflated their charges by separately billing the test under multiple current procedural terminology codes at a higher total cost to Tricare, prosecutors asserted. The unbundled claims made it appear as if the clinic performed more than one test and therefore was entitled to more than one payment from the government. The case was settled out of court following an investigation by the Department of Defense Criminal Investigative Service, Pitman said. He said the settlement agreement was not an admission of liability by Elemuren, Ogunmuyiwa, or Family Medicine Clinic.
RAC APPEALS USUALLY SUCCESSFUL: When hospitals have chosen to appeal Recovery Audit Contractor (RAC) Medicare claims denials, almost three-quarters (72 percent) of denials have been overturned as of the fourth quarter of 2012, according to the latest American Hospital Association (AHA) RACTrac survey. Michael Ward, AHA’s senior associate director for policy, says that the appeals overturned percentage is consistent with previous RACTrac surveys. “The numbers tell us that hospitals that choose to appeal have a pretty good success rate,” Ward said. The survey, which includes cumulative hospital RAC information from January 2010 through the end of 2012, found that hospitals have appealed roughly 40 percent of the 292,000 RAC denials issued over that time frame. The overturned RAC denials have a total value of $105 million, AHA said in the survey, released March 8.
