News: CareWell Urgent Care to pay $2 million to settle upcoding allegations

CareWell Urgent Care Centers, which operates 16 urgent care centers in Massachusetts and one in Rhode Island, has agreed to pay $2 million to settle whistleblower allegations that the company submitted inflated and upcoded claims to Medicare and Medicaid, according to the Department of Justice (DOJ).

According to a media release statement from CareWell, they reached the settlement after “fully cooperating with the inquiry.”

Between 2013 and 2018, according to the prosecutors, CareWell filed false claims with Medicaid, MassHealth, GIC, and Rhode Island Medicaid after inflating evaluation and management (E/M) services and failing to identify the clinicians providing the care, HealthLeaders Media reported.

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.

The company also ordered clinicians to use patient encounter templates within the clinics' EHR 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, HealthLeaders Media reported.

Prosecutors also allege that CareWell failed to reduce the amounts of its claims for services performed by unsupervised nurse practitioners.

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

Editor’s note: This article originally appeared in HealthLeaders Media. To read the DOJ summary of the case, click here. To read about the process for selecting an E/M code, click here.