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Quincy-Based Physician Group To Pay $650,000 To Resolve Allegations of False Billing to MassHealth

LEGAL NEWSLINE

Saturday, November 23, 2024

Quincy-Based Physician Group To Pay $650,000 To Resolve Allegations of False Billing to MassHealth

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The Massachusetts Attorney General’s Office (AGO) has reached a settlement with Evolve Health, P.C. (Evolve), a Quincy-based physician group practice specializing in substance abuse treatment. The settlement resolves allegations that the organization submitted false claims to MassHealth and MassHealth managed care entities (MCEs) by billing MassHealth for services that were not provided and billing for more expensive levels of service than actually provided. 

As part of the settlement, Evolve will pay $650,000 in restitution to the Commonwealth and will implement a three-year independent compliance monitoring program at its own expense. The compliance program will result in updated policies and procedures to ensure compliance with MassHealth and MCE requirements, along with trainings for staff on the updated policies and procedures, and annual record and on-site audits.  

Per its investigation, the AGO alleges that since at least January 2018, Evolve routinely submitted claims to MassHealth and MCEs for confirmatory urine tests that it did not provide. The AGO’s investigation indicated that Evolve did not own the equipment necessary to conduct the confirmatory urine tests that it billed to MassHealth and the MCEs. Additionally, the AGO alleges that Evolve “upcoded” some of its Evaluation and Management (E&M) office visits, billing for longer or more complex office visits than were actually provided. The AGO asserts that Evolve’s alleged conduct constituted the submission of false claims in violation of the Massachusetts False Claims Act and the Medicaid False Claims Statute. 

This matter is representative of the AGO’s ongoing efforts to hold accountable those who misuse roles of authority or public trust, including through abuse of the MassHealth program. Earlier this year, the AGO reached a $1.6 million settlement with two North Dartmouth ambulance companies to resolve similar allegations of fraudulent MassHealth billing, including for submitting “upcoded” claims. 

This matter was handled by Assistant Attorney General Natalie Rutkowski, Investigator Vanessa Asiatidis, and Senior Healthcare Fraud Investigator William Welsh, all of the AGO’s Medicaid Fraud Division. 

The AGO’s Medicaid Fraud Division is a Medicaid Fraud Control Unit, annually certified by the U.S. Department of Health and Human Services to investigate and prosecute health care providers who defraud the state’s Medicaid program, MassHealth. The Medicaid Fraud Division also has jurisdiction to investigate and prosecute complaints of abuse, neglect and financial exploitation of residents in long-term care facilities and of Medicaid patients in any health care setting.  Individuals may file a Medicaid/MassHealth fraud complaint or report cases of abuse or neglect of Medicaid patients or long-term care residents by visiting the AGO’s website.

The Massachusetts Medicaid Fraud Division receives 75 percent of its funding from the U.S. Department of Health and Human Services under a grant award totaling $5,922,320 for federal fiscal year 2025. The remaining 25 percent, totaling $1,974,102 for FY 2025, is funded by the Commonwealth of Massachusetts. 

Original source can be found here.

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