Metro-east doctor was cog in scheme that defrauded Medicare of $40 million, lawsuit states

The metro-east doctor who admitted to falsifying records to collect payment for services he didn’t provide was one small part of a broader scheme by his employer to defraud Medicare of more than $40 million over a nine-year span, according to a False Claims Act lawsuit filed by the federal government.

According to court documents, Dr. Phillip J. Greene, 59, of Edwardsville, was employed by General Medicine PC to provide healthcare services to nursing homes and assisted living centers throughout southern Illinois. As part of a plea agreement, he admitted guilt to a single charge of healthcare fraud for documenting examinations he didn’t perform and billing them through his employer for Medicare reimbursement.

A 96-page civil complaint filed in the U.S. Court for the Southern District of Illinois in 2022 alleges that it’s a practice General Medicine encouraged.

In the civil suit, the U.S. attorney argues that beginning in “at least” 2013, General Medicine knowingly billed Medicare for visits to patients that were not medically necessary, if they were performed at all.

It also alleges that the Michigan-based company set monthly patient-visit quotas for doctors and nurse practitioners “without any consideration as to whether the patients needed the services” and that it submitted inflated claims.

In some instances, including those to which Green admitted guilt, doctors completed progress notes containing inaccurate or embellished information to support higher reimbursement rates.

The suit also names 17 “shell companies” affiliated with General Medicine as defendants.

“Rather than focusing on caring for the vulnerable patient population they served and treating each resident based on their individualized needs, Defendants played a numbers game designed to bill as many patient visits as possible, regardless of whether those visits were actually performed as documented or medically necessary,” the complaint states.

“As one GM clinician put it: Defendants preferred quantity over quality.”

In its response to the lawsuit, General Medicine and owner Thomas M. Prose, M.D. deny the allegations, noting that so-called quotas were part of compensation plans that have since been changed and that, while some Medicare claims might have been falsified, the company did not submit them knowingly.

In cases where the company knew services were falsified, it either didn’t submit the claim or reimbursed Medicare, the answer states. The company also objects to the use of the term “shell companies” to describe its subsidiaries.

General Medicine operates clinics and employs healthcare clinicians in Illinois, Kansas, Missouri, Michigan, Louisiana, Iowa, Ohio, and North Carolina. The lawsuit alleges thousands of fraudulent claims, but specifically cites 27 examples of how the scheme was carried out.

Among them was one of Greene’s patients, which court records identify only as “E.S.” who resided at “Nursing Home 1 in Mascoutah.”

According to both the civil complaint and the criminal indictment, Greene claimed to have examined “E.S.” at the nursing home, after she had already been admitted to a local hospital for treatment of a variety of ailments.

Medicare again paid General Medicine PC $109.37 for services Greene recorded, but never performed.

The indictment against Greene spells out the circumstances of two other complaints against General Medicine related to services he later admitted he didn’t provide patients.

In one of them, he reported visiting “Assisted Living Facility 1 in Shiloh” to examine a patient identified as “D.B.” on Oct. 24, 2016.

“Greene well knew his representations were false because he had not actually examined D.B. at all on October 24, 2016,” the indictment says. “In fact, D.B. had died one day earlier on October 23, 2016.”

General Medicine PC put in a claim for $275, which Medicare denied.

In the other case described in court records, Greene generated a false progress report stating that he had examined “M.W.” at the Mascoutah facility on June 1, 2017. In it, he claimed to have checked M.W.’s head and face and observed no “swelling, deformity, acchymosis or erytheme.”

“In fact, M.W.’s face was bruised from a fall and she’d had a dozen stitches removed from her face the day before the purported exam,” the complaint stated.

Medicare reimbursed General Medicine PC $109. 37.

Greene routinely generated progress notes “he knew contained misrepresentations and materially false statements about the services he purportedly provided” and that he “knew General Medicine PC would use the false information he provided to support false claims for reimbursement to Medicare.”

In total, Greene billed $20,135 in false claims, for which Medicare reimbursed General Medicine $10,031. Greene’s personal share was $5,220, according to the court records.

Greene’s sentencing is scheduled for 10:30 a.m. on June 5. Healthcare fraud is punishable by up to 10 years imprisonment, a fine of up to $250,000, and up to three years of supervised release. Greene must also pay restitution for government losses.

An effort to settle the claims against General Medicine PC through a mediator failed and a judge denied a motion to dismiss the suit. A trial date has not yet been set.