Opinion ID: 212733
Heading Depth: 3
Heading Rank: 3

Heading: Internal Billing Discussions and Recommendations

Text: The complaint further alleges that NeuroMetrix, through its officers, knew that the billing practices it advised physicians to adopt were unsustainable. [2] It employed two separate directors of reimbursement with more than fifty years of collective CPT coding experience. Both of these experts advised Shai Gozani, President and Chief Executive Officer, and Gary Gregory, Chief Operating Officer, that they could not promote the use of the neurology-based codes in marketing the NC-Stat. The first such director advised the executives that NeuroMetrix should instruct physicians to use miscellaneous codes in the short term, which would, at best, pay one-third or one-fourth of what the existing neurology-based CPT codes paid to physicians. Id. at 16. The director advised that, in the longer term, the company needed to apply to the AMA for a new code for the NC-Stat procedure and, in advance of such application, that Neuro-Metrix should obtain certain peer-reviewed articles about the efficacy of the device. Mr. Gregory asked the director what amount physicians would be reimbursed in the interim, and was told `close to nothing' until the AMA `validated' the device. Id. According to the director, Mr. Gozani and Mr. Gregory hoped instead to `fly under the radar,' and Mr. Gregory specifically stated that the company `could not afford to tell physicians,' who were `making $250 a test' that `they would possibly get nothing.' Id. The director informed the executives that such course of proceeding was impossible due to the 10% rule, under which the increased use of the neurology codes was likely to spark a Medicare investigation. The director informed them that Medicare knows which physiciansprimary care or neurologistsare seeking reimbursement, because physicians also have a specific identification number included in reimbursement requests. The director advised that recommending the use of improper codes would be Medicare fraud. This first director resigned after the company refused to change its policy. The company's second director of reimbursement, Jan Foote, also advised the company to apply for a new, device-specific code for the NC-Stat. She told an employee that Mr. Gregory and Mr. Gozani wanted to wait until problems with the AMA actually materialized before making any changes. Id. at 18. She also resigned out of frustration. Id. According to the complaint, sales and customer service staff confirm that they were instructed to recommend the neurology billing codes to customers. NeuroMetrix used actual reimbursement payment receipts from other offices as verification of reimbursement under the recommended codes. Specifically, if a physician was skeptical about the precise amount of expected insurance reimbursement it would receive after using the NC-Stat System, sales representatives would provide purported actual payment slips from Aetna, Blue Cross, or Medicare to prove that payment had been received in other offices. ... Id. at 20. The complaint further details the manner in which the individual defendants were involved in the billing issues. Notably, after physicians started to complain that a particular insurer had a coverage ban on NC-Stat procedures, Mr. Gozani allegedly told physicians not to worry; he noted that, if billed using the general neurology codes, the insurer could not discern whether the NC-Stat or traditional neurologic tests were performed. As a consequence, according to Mr. Gozani, it could not enforce its ban.