Provided by: Jennifer Kirschenbaum, Esq.
February 4, 2025
According to the Department of Justice (https://www.justice.gov/usao-edpa/pr/philadelphia-mental-health-clinic-and-its-psychiatrist-owner-agree-pay-900000-resolve), a Philadelphia based psychiatrist has agreed to settle False Claims allegations for $900,000. see United States v. Nueva Vida Multicultural/Multilingual Behavioral Health, Inc. and Ghodrat Pirooz Sholevar, M.D., Civ. No. 24-1451 (E.D. Pa.). In this instance, the False Claims allegations stemmed from medication management services. In this instance, the government contended that over a period of 8 years, the provider did not meet the 15 minutes per "unit" of service requirement for the CPT code submitted to the Medicaid system, inter alia,
"The defendants’ fee schedules for services to Medicaid patients specified that the medication management visit was 15 minutes per “unit” of service billed. The defendants were notified in an audit as early as 2004 that medication management visits ranging from six to twelve minutes were too short. The Medicaid program administrator also regularly recouped payments from the defendants for medication management visits that did not include start and end times, or where there was evidence that the appointment was less than 15-minutes long. But the defendants continued providing too-short appointments and failing to document clock times in treatment records, even after these issues were repeatedly brought to their attention. Nueva Vida ceased operating mental health clinics in 2018." See.
Interestingly, the press release for this matter states "The claims resolved by the settlement are allegations only and there has been no determination of liability." which is a reminder that most matters settle before the government actually proves its case - the defendant is often put into a situation where paying a pound of flesh is the selected exit strategy, perhaps to avoid criminal charges or more legal fees. See
Why is this relevant to you? As a reminder to review your documentation and billing practices! For providers, this case serves as a clear warning. Practices must ensure that every provider delivering services is properly credentialed, every claim is supported by accurate records and compliance policies are in place to prevent errors. Even unintentional mistakes can lead to significant financial penalties, and when misconduct appears intentional (such as falsifying records) the consequences can be far worse, including criminal charges.
Especially if your practice bills Medicaid or Medicare, it is incredibly important to regularly (at least annually) take the time to conduct compliance audits - bring in a third party medical documentation expert to have your charts reviewed. If you need a recommendation, ask. We work closely with HBMA, the national billing and coding association and we are happy to send you a few independent professionals to vet.
"The defendants’ fee schedules for services to Medicaid patients specified that the medication management visit was 15 minutes per “unit” of service billed. The defendants were notified in an audit as early as 2004 that medication management visits ranging from six to twelve minutes were too short. The Medicaid program administrator also regularly recouped payments from the defendants for medication management visits that did not include start and end times, or where there was evidence that the appointment was less than 15-minutes long. But the defendants continued providing too-short appointments and failing to document clock times in treatment records, even after these issues were repeatedly brought to their attention. Nueva Vida ceased operating mental health clinics in 2018." See.
Interestingly, the press release for this matter states "The claims resolved by the settlement are allegations only and there has been no determination of liability." which is a reminder that most matters settle before the government actually proves its case - the defendant is often put into a situation where paying a pound of flesh is the selected exit strategy, perhaps to avoid criminal charges or more legal fees. See
Why is this relevant to you? As a reminder to review your documentation and billing practices! For providers, this case serves as a clear warning. Practices must ensure that every provider delivering services is properly credentialed, every claim is supported by accurate records and compliance policies are in place to prevent errors. Even unintentional mistakes can lead to significant financial penalties, and when misconduct appears intentional (such as falsifying records) the consequences can be far worse, including criminal charges.
Especially if your practice bills Medicaid or Medicare, it is incredibly important to regularly (at least annually) take the time to conduct compliance audits - bring in a third party medical documentation expert to have your charts reviewed. If you need a recommendation, ask. We work closely with HBMA, the national billing and coding association and we are happy to send you a few independent professionals to vet.
