American Family Care Inc. has agreed to pay the government $1.2 million to resolve allegations under the False Claims Act that it knowingly submitted claims to Medicare for outpatient office visits that were billed at a higher rate than was appropriate. American Family Care is a network of walk-in medical clinics headquartered in Birmingham, Alabama, with offices in Alabama, Tennessee and Georgia.
Following guidance adopted by the Centers for Medicare and Medicaid Services, health clinics such as American Family Care bill Medicare for their services by selecting a corresponding Evaluation and Management code. The codes are divided into five different levels - from basic (level 1) to most complex (level 5). Higher level codes result in higher reimbursement from Medicare than lower level codes. The government alleged that American Family Care knowingly selected Evaluation and Management codes for a level of services that exceeded those actually provided in order to artificially increase the amount of reimbursement it received for those visits.
The civil settlement resolves a lawsuit filed by a former employee of American Family Care, under the whistleblower provision of the False Claims Act, which permits private parties to file suit on behalf of the government for false claims and to obtain a portion of the government’s recovery. Her share has not yet been determined.
See the DOJ Announcement