Geico v. 79444
In Geico v 79444 filed in 2019, Geico claimed that a PTP was taking place. Geico claimed that:
- An impossible number of patients had listed on their examination report that the “Soto Hall” test was positive for “a fracture at C7 and/or T1”.
- The initial exams were all billed as a 99203 even though some patients required a level 1 or a level 5. Geico made a big deal about every patient getting billed for a 99203.
- The provider billed 77003 (fluoroscopic guidance) even though that is included whenever a provider performs pain management injections.
- The provider was billing for pain management injections within the first three months (sometimes the first week) of treatment and before the patient failed conservative treatment.
- The provider performed EMC’s “in-house” with their PA’s and that virtually every patient received an EMC including minor children and patients who presented with low levels of pain.
- The provider billed for 110 CPT Codes of therapy (chiropractic/physical therapy codes including hot/cold packs) on 16 patients in one day which is an average of 6.78 CPT codes per visit. This also represents anywhere from 960 minutes in a single day (15 minutes times 4 CPT Codes times 16 patients) to 27 hours/1627 minutes in a single day (15 minutes times 6.78 CPT Codes times 16 patients). Geico is only one insurance company so that means when you add in the State Farm, Progressive, Allstate, etc. insurance companies that there are probably over 100 hours of time in a single day and being “supervised” and “performed” by a single chiropractor on any given day.
Geico claimed a violation of Chiropractic Advertising Laws based on their website. For instance, the website stated that: (1) the chiropractor owned a referral company under his same last name and that the referral company violated chiropractic advertising laws by failing to mention the name of the chiropractor who owned the company and by failing to list the names of the treating physicians; (2) “insurance companies can deny weak claims… they can go to great lengths to find ways not to pay weak claims… you need someone on your side to help you strengthen your claim quickly… the sooner you call the more we can help… we work with you to effectively assess and address your injuries, which helps strengthen your claim…call from the ambulance, ER, or scene… we are your advocate…we provide documentation on what improves your claim and know what doesn’t improve your claim…we can help move your case full speed ahead…
Geico claimed that the chiropractic clinics weren’t properly supervised even though they were owned by a licensed chiropractor. Remember, Florida Statute still requires the “physician owner” to properly supervise the location. Geico also claimed that the owner was a chiropractor and, therefore, never qualified as an exempted clinic because they performed services (prescribing drugs, pain management injections and surgery) which were outside the scope of chiropractic. In other words, the chiropractor cannot prescribe drugs, perform injections, or perform surgery so how could he properly supervise the clinic and ensure patient safety which is the intent behind AHCA licensure.
DISCLAIMER
This is based on a real court case that was previously filed against a medical provider/doctor. The case number has been partially redacted and names have been changed to protect the Defendants’ names. This example is posted to help educate others on the laws and potential pitfalls. This posting is not intended to embarrass or defame anyone. I have limited the information and simplified some of the facts in the lawsuit to reflect key points and make a complicated case easier to understand. This “example” is directly from a complaint filed by an insurance company; therefore, I am using the facts THEY presented. There are always two sides to a story so please understand this is just one side of the story. This information was found through records available to the public.