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Let’s Be Reasonable

Let’s Be Reasonable

Healthcare-Medicaid-4
Senior Director of Strategic Alliances
LexisNexis Risk Solutions - Government

An Iowa ear, nose, and throat doctor facing allegations of false Medicaid claims for endoscopic sinus surgeries contends that “reasonable people can disagree about the best medical options.” (But how reasonable it is to disagree on 115 medical procedures from one physician in one year?)

Dr. Tracey Wellendorf was accused of performing up to 115 sinus surgeries that didn’t meet Medicaid’s standards for medical necessity or were incorrectly coded on Medicaid claims from fall 2014 through fall 2015. According to an Office of the Inspector General agent in the U.S. Department of Health and Human Services (HHS), “medically unnecessary services pose potential harm to patients and place needless burdens on taxpayers who fund government health programs.” The allegations were brought following investigation by the HHS Office of the IG and Iowa’s Medicaid Fraud Control Unit.

While admitting no wrongdoing, Wellendorf agreed to paid $1 million to resolve the False Claims Act allegations. He also entered into an integrity agreement with the HHS Office of the IG, requiring him to undertake enhanced compliance measures for the next three years.

In a written statement, Wellendorf said he’s “happy and relieved” to resolve an “expensive, time-consuming and distracting” matter. (Sounds reasonable to me. Unnecessary surgeries are undoubtedly expensive, time-consuming and distracting for unsuspecting patients as well.)

Today’s Fraud of the Day comes from the Northern District of Iowa U.S. Attorney’s media release, “Northwest Iowa Otolaryngologist Agrees to Pay $1,000,000 To Resolve Medicaid False Claims Allegations,” published Oct. 15, 2019.

Dr. Tracey Wellendorf, an otolaryngologist with a clinic in Carroll, Iowa, agreed to pay $1,000,000 to resolve False Claims Act allegations relating to as many as 115 procedures performed on Iowa Medicaid beneficiaries between October 13, 2014, and November 27, 2015.

The allegations relate to claims for endoscopic sinus surgeries. The United States alleges that the claims submitted for the subject procedures were improper either because they did not meet the applicable medical necessity standard or were otherwise incorrectly coded for payment.

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