A Kentucky physician has agreed to pay $250,000 to resolve allegations that he and his practice submitted false claims to Medicare, Medicaid, and TRICARE related to improper billing for services provided by nurse practitioners, US Attorney Kyle G. Bumgarner of the Western District of Kentucky announced on August 27, 2025.
Medicare, Medicaid, and TRICARE reimburse for medical services provided by nurse practitioners, but at different rates than if the services were provided by a physician. The United States alleged that the physician and his practice violated the False Claims Act by billing these programs as if he personally provided the services, when in fact they were performed by nurse practitioners.
For Medicare, services provided by nurse practitioners may sometimes be billed under a physician’s name if certain conditions are met. However, the United States alleged that the physician and his practice failed to meet those conditions.
The Kentucky Office of Attorney General’s Medicaid Fraud Control Unit assisted in the investigation and received over $68,000 of the settlement due to the false claims submitted to Medicaid. The US Department of Health and Human Services’ Office of Counsel to the Inspector General and Office of Investigations also contributed to the investigation and settlement.
According to the press release, the investigation and resolution of this case reflects the government’s continued focus on addressing healthcare fraud.
Compliance Perspective
Issue
Healthcare providers are responsible for ensuring that claims submitted to Medicare, Medicaid, and other federal healthcare programs accurately reflect the services provided and who provided them. Submitting claims that misrepresent the provider of service, even unintentionally, can result in significant liability under the False Claims Act. Services delivered by qualified non-physician providers may be billed to government programs, but the billing must follow program requirements. Inaccurate or unsupported claims can trigger investigations, repayments, and penalties.
Discussion Points
- Review your billing policies and procedures to ensure they clearly outline when and how services delivered by different types of providers may be billed. Include safeguards to help prevent misrepresentation of who performed the service. Policies should be reviewed regularly and updated when billing rules or guidance change. Facilities may benefit from working with a consultant to evaluate existing policies and ensure they reflect current regulatory expectations.
- Train clinical, administrative, and billing staff on your facility’s billing policies and the importance of accurately identifying the provider of service. Emphasize the risks of submitting claims that do not follow program rules. Med-Net Academy offers a course titled Origin of Fraud that covers the role of federal enforcement agencies, the origin of fraud in healthcare settings, and the components of an effective compliance and ethics program. For staff involved in Medicare billing, ensure training includes instruction on the Triple Check Process to verify accuracy before claim submission.
- Conduct periodic audits to verify that billing practices align with program requirements and internal policies. Review documentation to ensure it supports who provided each service and how it was delivered. Facilities may find it helpful to engage an external consultant for focused reviews or mock audits, especially when preparing for surveys or evaluating high-risk areas. Use audit findings to strengthen internal processes and ensure compliance concerns are addressed proactively.
*This news alert has been prepared by Med-Net Concepts, Inc. for informational purposes only and is not intended to provide legal advice.*