Doctor Involved in Nursing Home Medicare Fraud Case Settles for $700,000

| February 5, 2013

A Stratford, Connecticut doctor has decided to settle rather than go through an extensive trial and accompanying costs related to allegations of fraudulently billing Medicare for services rendered at area nursing homes. 

The United States Attorney for the District of Connecticut brought allegations against Dr. James Ralabate and his company, Primary Care Associates, involving fraudulent billing to Medicare occurring throughout a five-year period for medical services provided at various nursing homes, according to a release. 

Ralabate allegedly billed Medicare for high-level physician services when the services of a physician were not medically necessary, and medical records fail to meet the detailed history, examination, or medical decision-making requirements necessary to justify the high level of physician care, the attorney’s office said. Additionally, at times, no medical record documented Ralabate’s visit. 

The government also accused Ralabate of billing Medicare for services supposedly rendered to patients in nursing homes when those patients weren’t actually present in the nursing homes but rather had been transferred to local hospitals for treatment. Despite a difference in locations, Ralabate billed government healthcare programs as if he had provided medical services in the nursing homes.

The alleged fraudulent billing activity took place between Jan. 1, 2006 and Aug. 31, 2011. Although Ralabate and his company agreed to pay $700,000 in order to reimburse the Medicare programs and resolve liability under the False Claims Act, the physician denies wrongdoing.

“Prior detailed audits by CMS proved that only 2 out of 54 procedures/services studied were coded higher than the documentation supported and only 1 was thought to be for more services than necessary, while 14 were actually under-coded,” says a statement from Ralabte’s office. “Even though he provided more services than his peers, 98.2 percent of the services studied extensively were found to be medically necessary. This prior audit actually resulted in increased payments to Dr. Ralabate.” 

Only after Ralabate learned that an audit had found his medical services records to be “beyond what Medicare pays for” did he choose to settle the case, “rather than take time away from his patients and pay legal bills for the trial,” his office says in the statement. 

The doctor also responded to the allegations that he billed Medicare for nursing home services while patients were in the hospital, saying that he did in fact visit and provide his services to those nursing home patients and never billed for services that were not provided.

“The financial settlement was only based upon the Government’s belief that some health services were miscoded, or provided more care than Medicare would pay for,” says the statement from Ralabate’s office, and the doctor has chosen to hire billing and coding experts to prevent any risk of noncompliance.

Written by Alyssa Gerace


Category: Medicare and Medicaid, Nursing Homes, Senior Care, Senior Housing

Comments (1)

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  1. Chris_Foley says:

    Nicely balanced article. Great attention to detail related to the complicated billing process. Thank you for the full story including past audit histories (great investigative reporting). It seems like a lot of general reporting just has enough facts to support the headline. This is a truly balanced report from SHN with positives, negatives, prior history and current news.

    Many reporters would not have included: “Prior detailed audits by CMS proved that only 2 out of 54 procedures/services studied were coded higher than the documentation supported and only 1 was thought to be for more services than necessary, while 14 were actually under-coded,” says a statement from Ralabte’s office. “Even though he provided more services than his peers, 98.2 percent of the services studied extensively were found to be medically necessary. This prior audit actually resulted in increased payments to Dr. Ralabate.”

    Chris Foley
    Sr. V. P.
    Equity National Seniors Housing Brokerage & Advisors
    cfoley@Equity.net