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Analysis

CareWell Urgent Care to Pay $2M to Resolve Upcoding Allegations

By John Commins  
   April 01, 2019

Prosecutors allege that CareWell executives developed schemes to create mandatory but unnecessary examinations that were billed to state and federal healthcare programs.

CareWell Urgent Care Centers will pay $2 million to settle whistleblower allegations that the company submitted inflated and upcoded claims to Medicare and to Medicaid programs in Massachusetts and Rhode Island, the Department of Justice said.

According to state and federal prosecutors, between 2013 and 2018, Quincy, Massachusetts-based CareWell filed false claims with Medicaid, MassHealth, GIC, and Rhode Island Medicaid after inflating evaluation and management services and failing to identify the clinicians providing the care.

CareWell allegedly used several schemes, including ordering clinicians to unnecessarily examine and document at least 13 body systems during medical history inquiries, and at least nine body systems during physical examinations.

This unnecessary documentation was compiled even if patients' medical complaints or symptoms did not warrant it, prosecutors said.

CareWell ordered clinicians to use patient encounter templates within the clinics' electronic medical records that used "yes or no" questions about specific body systems, even when such inquiries were not medically necessary, prosecutors said.

"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," prosecutors alleged. "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."

CareWell managers also allegedly lied to clinicians and told them that examinations unrelated to a patient's specific medical complaints or symptoms were required by a malpractice insurance carrier.

Prosecutors also allege that CareWell failed to reduce the amounts of its claims 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 Andrew E. Lelling, U.S. Attorney for the District of Massachusetts.

The settlement resolves whistleblower allegations brought by former CareWell employee Aileen Cartier, who will collect about $340,000.

CareWell Responds

CareWell said in a media release that it reached the settlement "after fully cooperating with the inquiry."

"We believe it is crucial to be thorough with each patient's examination in order to provide the best possible care," the company said.

CareWell operates 16 urgent care centers in Massachusetts, and one in Rhode Island.

“The CareWell urgent care centers engaged in a calculated scheme to reap unjustified economic benefit for their own gain from precious government healthcare resources.”

John Commins is a content specialist and online news editor for HealthLeaders, a Simplify Compliance brand.


KEY TAKEAWAYS

The unnecessary documentation was compiled even if patients' medical complaints or symptoms did not warrant it.

CareWell also allegedly lied to clinicians and told them the unneccessary examinations were required by a malpractice insurance carrier.

CareWell said that it reached the settlement 'after fully cooperating with the inquiry.'


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