Huge Upcoding Scheme Alleged in Physician House-Call Company

August 30, 2013

In 2007, Dike Ajiri, the chief executive officer of Mobile Doctors, received an email from a physician with advice on how to bill Medicare for house calls, according to a federal investigator.

The guidance focused on home visits with established patients, which can be coded at 4 levels of complexity and reimbursement. The lowest billing code pays about $54; the highest, almost $174.

"One of the easiest ways to catch fraud crooks," the physician noted, "is that they foolishly bill everything the same."

Federal law enforcement officials say Ajiri wound up doing just that.

On August 27, Ajiri and one of his most productive physicians were arrested on Medicare fraud charges as federal agents raided the company's headquarters in Chicago, Illinois, and branch offices in Detroit, Michigan, and Indianapolis, Indiana. A criminal complaint against the 2 men filed in a federal district court in Chicago said that the company's physicians, working under contract, typically spend 10 to 30 minutes with each patient on routine medical issues, yet Mobile Doctors invariably bills Medicare with the 2 highest codes — 99349 and 99350 — as if the visits are more complicated and last between 40 and 60 minutes.

The criminal complaint stated that from 2006 to 2012, Mobile Doctors received roughly $21 million from Medicare for house calls coded 99349 and almost $13 million for those coded 99350.

By design, the 2 lower-paying codes — 99347 and 99348 — were not in play, according to the complaint.

"I don't pay for one's and two's," Ajiri is quoted as telling his physicians, who make 7000 house calls per month in Arizona, Illinois, Indiana, Michigan, Missouri, and Texas, according to the Mobile Doctors Web site. Ajiri is also quoted as saying that 99349 is the default code for visits, "so that the payment...would be worth the gas and time spent."

Table. What Medicare Pays for House Calls With Established Patients

Billing Code Typical Amount of Face-to-Face Time Fee (National)
99347 15 minutes $54.44
99348 25 minutes $82.34
99349 40 minutes $124.86
99350 60 minutes $173.52

Source: Centers for Medicare & Medicaid Services.

Former and current employees of Mobile Doctors went to authorities with stories of fraudulent billing practices, and in the end, almost 30 were interviewed by federal agents, the complaint stated. Among them were several physicians, including one who had confronted Ajiri about the common back-office practice of upcoding visits to 99350 after a physician had chosen a lower code, according to the complaint.

Ajiri's lawyer, Darryl Goldberg, said his client will plead not guilty.

"Although the government makes serious and sweeping allegations in a criminal complaint the size of a small phone book, there is much that seems, at this point, to be unsubstantiated," Goldberg told Medscape Medical News in an email. "In essence, the government complaint alleges 'health care fraud,' primarily based on what has been referred to as 'upcoding' [Current Procedural Terminology (CPT)] codes for patients of Mobile Doctors.

"However, the complexity of CPT coding is widely known, and the government has the incredibly high burden of proving, beyond a reasonable doubt, that Mr. Ajiri knowingly and willfully participated in a scheme to defraud Medicare."

Ajiri is free on a $3 million bond.

Supposedly Homebound Patient Could Walk a Mile

The investigation into Mobile Doctors by agents from the Federal Bureau of Investigations, the Department of Health and Human Services, and the Railroad Retirement Board also netted a physician named Banio Koroma, MD, who, similar to Ajiri, was charged with a single count of healthcare fraud.

The criminal complaint said that Mobile Doctors billed more home visits for Dr. Koroma than for any other physician working with the company from 2006 through March 2013. He was also tops when it came to certifying that patients were confined to their homes and required services from a home health agency. From August 2007 to March 2013, Dr. Koroma completed roughly 6000 certifications, which were billed to Medicare.

The fraud charge against Dr. Koroma centers on certifying patients as home-bound. The complaint stated that similar to other company physicians, Dr. Koroma certified patients who were too ambulatory and active to be considered confined to their home. One of Dr. Koroma's patients, for example, "is able to walk a mile," a physician told investigators.

Dr. Koroma was released on a $50,000 bond. His attorney, Edward Genson, did not respond to a request for an interview.

Mobile Doctors allegedly had an incentive to certify as many patients as possible for home-health services: Ajiri's' company received most of its patient referrals from home-health agencies, and certifying patients for them in a quid pro quo relationship kept the referrals flowing, according to the criminal complaint.

"They Won't Investigate Me Over One Test"

The federal case against Ajiri and Dr. Koroma alleges other intrigues. The complaint stated that:

  • "Probable cause exists" that Mobile Doctors falsified bills for echocardiograms to make it appear as if the company's physicians had taken and interpreted them when it in fact they were handled by another company owned by Ajiri and the head biller for Mobile Doctors.

  • Former employees said Ajiri wanted 3 diagnoses listed for each visit for the sake of a higher-level code. Physicians who listed only 2 were encouraged to tack on a third — osteoarthritis was a common one — after the visit. One physician called some of them "bogus."

  • Mobile Doctors ordered medically unnecessary tests, often through standing orders that nonphysicians would carry out. Some physicians refused to sign such standing orders; others authorized them unwittingly.

A former employee told investigators that the company often would justify tests by saying the patient had diabetes. One time, when a patient's diagnosis was not clear, she received instructions from her boss not to bother double-checking with the physician, according to the criminal complaint.

"Just give them the diagnosis," the former employee quoted Ajiri as saying. "They won't investigate me over one test."

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