Opinion ID: 2652557
Heading Depth: 3
Heading Rank: 2

Heading: Blue Cross/Blue Shield

Text: In addition to operating Bayou and working at Morehouse General, Martin, in her individual capacity, enrolled as an LPN provider with Blue Cross/Blue Shield (“Blue Cross”). 3 In that role, she cared for two Blue Crossinsured patients, C.S. and E.D. Billing to Blue Cross was based on current procedural technology (“CPT”) codes. CPT codes were developed by the American Medical Association, and consist of five-digit codes that represent a specific service provided by the biller. Each claim included information about the patient, the insured, and the services provided. 3 Although not disputing that she enrolled as an individual LPN provider, Martin contends that Cotton advised and assisted her in obtaining her provider number. 4 Case: 12-31275 Document: 00512524708 Page: 5 Date Filed: 02/06/2014 No. 12-31275 Although initially billing Blue Cross between $450 and $500 per day of care for each of her two patients, Martin, in less than a year, began submitting daily care charges for as much as $800, and for as much as $1,600 a short time later. Martin’s submission of claims exceeding $800,000 “in a very short period of time” led Blue Cross to commence an investigation. As part of this investigation, Blue Cross asked Martin for the patients’ records. Martin proved “not very cooperative,” and Blue Cross had to make repeated efforts to get Martin to produce the requested documents. Blue Cross was also contacted by a woman identifying herself as Susan Turner, who stated that she would be Martin’s point-of-contact. Susan Turner was “very aggressive” and challenged Blue Cross’s authority to access the records. Blue Cross eventually warned Martin that if the records were not provided, it would seek to recoup the over $800,000 Blue Cross had paid her. Martin supplied the records Blue Cross demanded in December 2008. Unlike the claims Martin had previously filed utilizing CPT codes, these records consisted of nurse notes, which included, among other things, the date and times care was provided; the type of care; and patient information such as vital signs, fluid intake and output, and bowel movements. The nurse notes were signed by Martin. Comparing Martin’s nurse notes with the times Martin clocked in to her full-time job revealed that Martin was billing Blue Cross for services allegedly performed on days she was working at Morehouse General. For example, on February 12, 2007, Martin’s records state that C.S. was dressed, bathed, fed, and transferred; his urine output and bowel movements were measured; and medications were provided at 11 a.m., 2 p.m., 5 p.m., and 10 p.m. Martin billed Blue Cross $500 for these services. That same day, Martin began work at Morehouse General at 6:35 a.m., and remained there until 6:56 p.m. 5 Case: 12-31275 Document: 00512524708 Page: 6 Date Filed: 02/06/2014 No. 12-31275 Additional analysis of Martin’s records showed that on three occasions she billed Blue Cross for services provided to a patient while he was hospitalized. In one instance, C.S. was hospitalized on February 6, 2007, and discharged on February 8, 2007. Martin’s records stated that C.S. was provided homecare on each of the three days he was in the hospital, for which Martin billed Blue Cross a total of $1,500. Martin also continued to work fulltime at Morehouse General during this time. As already noted, Martin’s billing practices also fluctuated significantly between February 2007 and September 2008. Although the services for which Martin billed Blue Cross did not change, the amount she charged increased, with isolated exceptions, substantially. As to E.D., Martin’s claims increased from $450 per day of care in July 2007, to $600 in September 2007, and finally to $800 in December 2007. For C.S., Martin billed Blue Cross $500 per day of care from February 2007 to May 2007. From June 2007 to November 2007, Martin increased her daily charges to $700. Between February 2008 and September 2008, Martin’s daily care charges then ranged from as low as $800 to as high as $1,600, before settling at $1,000. In all, Blue Cross paid Martin $813,422.50, of which $200,853 was for services allegedly rendered on days she worked at Morehouse General, or while C.S. was hospitalized.