The Massachusetts Attorney General’s Office (AGO) announced on November 4, 2025, that it reached a settlement with a physician and his practice to resolve allegations of submitting false claims to MassHealth. The AGO alleged that the physician billed for services he said he personally provided to MassHealth members, when in fact those services were performed by physician assistants and nurse practitioners.
Under the agreement, the physician and his practice will pay $175,000 and participate in a three-year independent compliance monitoring program at their own expense. The program will include updated policies, annual training on relevant laws and regulations, and yearly audits, with results reported to the AGO.
MassHealth allows midlevel practitioners, such as physician assistants and nurse practitioners, to provide care under a physician’s supervision. However, these services are reimbursed at 85 percent of the physician rate. The AGO’s investigation found that, between January 1, 2019, and January 1, 2025, the physician submitted claims as though he had provided the services himself.
The inquiry began after a referral from MassHealth.
Compliance Perspective
Issue
Healthcare providers are responsible for ensuring that all claims submitted to Medicaid, Medicare, and other payers accurately represent the services provided, who performed them, and that those services were delivered by appropriately licensed and qualified individuals. Submitting claims that incorrectly identify the rendering provider or do not reflect the actual delivery of care may result in overpayment or potential violations of federal and state False Claims laws. These issues can lead to financial penalties, required repayments, and corrective action plans. Maintaining clear policies, staff education, and regular auditing processes helps reduce the risk of billing errors and supports overall compliance with payer and regulatory requirements.
Discussion Points
Review your policies and procedures to make sure they clearly explain who is allowed to provide and document services and how those services should be billed. Policies should also address supervision and credentialing requirements. Working with a qualified healthcare compliance consultant can help organizations identify potential policy gaps, strengthen internal processes, and maintain readiness for review or survey.
Provide ongoing education for staff involved in providing care, documentation, or billing. Training should emphasize the importance of accurate documentation, working within licensure and scope of practice, and understanding how billing errors can create compliance risks. Med-Net Academy offers the course Fraud Module 16 – Financial Integrity, which addresses accurate billing, medical necessity, verifiable documentation, and protocols for maintaining financial compliance.
Perform regular audits to confirm that documentation supports the services billed and that claims correctly reflect who provided the care. Audits should also check that supervision and credentialing requirements are being met. Some organizations find it helpful to work with a consultant for focused reviews or mock surveys to identify and address issues early.
*This news alert has been prepared by Med-Net Concepts, Inc. for informational purposes only and is not intended to provide legal advice.*