Urgent Care Centers Settle E/M Upcoding Charges for $2 Million

Case: The owners/operators of CareWell urgent care centers in Massachusetts and Rhode Island have agreed to shell out $2 million for improper coding of Evaluation and Management services. CPT code selection for E/M services is based on the number of body systems a provider must evaluate to diagnose a patient and who does the examination, e.g., nurse practitioner or physician. CareWell is accused of falsely inflating the level of E/M services performed and failing to properly identify who provided them. The whistleblower who brought the initial claim will get 17% of the recovery.

Significance: The part of this case that’s relevant to labs are the alleged methods CareWell used to carry out the upcoding scheme, which are analagous to things labs have been charged of doing to inflate coding for testing services, including:

• Requiring medical staff to examine and document at least 13 body systems during medical inquiries and 9 systems during physical exams regardless of patients’ actual complaints;
• Uploading encounter plan templates onto electronic medical records software asking “yes/no” questions about particular body systems that medical personnel had to ask each patient regardless of whether those questions were medically necessary; and
• Programming the template to list “no” as the default answer to any question that wasn’t asked to make it look like the particular body system to which the question related was examined.