Lawsuit Alleges False Claims Act Conduct at Pain Management Clinics in Tennessee, North Carolina and Virginia
NASHVILLE, Tenn. – November 16, 2018 –U.S. Attorney Don Cochran for the Middle District of Tennessee announced today that the United States has filed a False Claims Act lawsuit against Franklin, Tennessee-based Pain, MD, LLC and related companies, and their owners Michael Kestner and Lisabeth Smolenski Williams. The lawsuit alleges that the defendants knowingly and routinely submitted, or caused to be submitted, false claims to Medicare and TRICARE for single tendon origin or insertion injections (“TOI”) that they knew or should have known were not provided to patients. TOI injections are pain-relieving injections commonly used to treat such tendon related conditions as tendonitis and are not limited by Medicare or TRICARE as to the allowable number billed. In contrast, other treatments, such as trigger point injections are limited to four per year.
According to the complaint, Michael Kestner is a non-practicing attorney with no medical training, who owns, operates and controls MedManagement, Inc. (“MMI”), a management company located in Franklin, Tennessee. Lisabeth Williams is a physician and the Chief Medical Officer and minority owner of Pain, MD. She also served as a supervising physician or medical director for the pain clinics at certain times, with oversight for provision of all of the medical care and services provided by the pain clinics to their patients. MMI manages and has managed Pain, MD, Mid-South Pain Management, P.C.; Cumberland Back Pain Clinic, P.C.; Lebanon Back Pain Clinic, P.C.; Blue Mountain Medical Group, P.C.; Natural Bridge Medical Group, P.C.; and Rock Island Medical Group, P.C.
The United States alleges that from at least 2010 through October 2018, Kestner and Williams devised a scheme to operate interventional pain management clinics in Tennessee, North Carolina and Virginia, and fraudulently bill Medicare and TRICARE for TOI injections that were not actually injections into tendons at all. Through this scheme, Kestner and Williams recruited providers, including mid-level medical providers such as nurse practitioners and physician’s assistants, to the pain clinics and trained, pressured, and coerced them into performing high numbers of injections into patients’ back muscles, and then bill for these injections as if they were TOIs. The corporate pressure to meet the targeted goal of being within 15% of the top-biller of TOIs resulted in the pain clinic providers routinely giving patients six to eight injections per visit and sometimes as many as 12 injections into the back muscles, which were then billed as TOIs. During parts of the time period alleged in the lawsuit, patients were required to submit to the injections as a condition of treatment and remaining a patient of the practice. As a direct result of these practices, the defendants, either directly or indirectly, submitted false claims to Medicare and TRICARE and received millions of dollars in reimbursement from federal health care programs to which they were not entitled.
For the period from June 1, 2010 through December 31, 2015, the Medicare program paid the defendant pain clinics approximately $3 million for fraudulent services billed for Medicare beneficiaries treated at the clinics. For the period from March 6, 2014 through October 18, 2018, the TRICARE program paid Pain, MD approximately $288,000 for fraudulent services billed for TRICARE beneficiaries treated at clinics under their control.
Congress established the Medicare Program in 1965 to provide health insurance coverage for people age 65 or older and for people with certain disabilities or afflictions. Medicare Part B covers services like doctors’ and nurse practitioners’ visits and medical supplies. TRICARE (formerly known as CHAMPUS) is a federal health care program that provides health care insurance for active duty military personnel, military retirees, and military dependents.
The case is docketed as United States v. Michael Kestner, et al. (M.D. Tenn.). Assistant U.S. Attorney Ellen Bowden McIntyre represents the United States. Investigative support is provided by the Office of Inspector General of the U.S. Department of Health and Human Services and the Tennessee Bureau of Investigation. The claims in the complaint are allegations only, and there has been no determination of liability.