EMPIRE MEDICAL LLC

Evidence tier 1: documented action, then payment. Dollars at stake are $2,389,353, taken from the detector that set the tier. Listed on the Medicare revocation list since July 31, 2020. Medicaid still paid claims in 9 later months, $2,389,353 in total. Medicaid dollars per patient on code 99214 ($117 per patient-month) sit in the top 5% of every provider billing that code. Medicare revoked billing privileges on July 31, 2020 under 42 CFR 424.535(a)(9) failure to report and 424.535(a)(3) felonies.

1. 01Evidence tier 1: documented action, then payment. Dollars at stake are $2,389,353, taken from the detector that set the tier. records 2
2. 02Listed on the Medicare revocation list since July 31, 2020. records 3
3. 03Medicaid still paid claims in 9 later months, $2,389,353 in total. records 4
4. 04Medicaid dollars per patient on code 99214 ($117 per patient-month) sit in the top 5% of every provider billing that code. records 5
5. 05Medicare revoked billing privileges on July 31, 2020 under 42 CFR 424.535(a)(9) failure to report and 424.535(a)(3) felonies. The bar on re-enrolling runs to July 31, 2030. records 6
6. 06The Medicare revocation list action is dated July 31, 2020. Medicaid then paid $2,389,353 across 9 later months, from August 2020 to April 2021. The screening window closes on July 31, 2030. In the 12 months before the action Medicaid paid $3,888,239. records 7
7. 07Code 80307, Testing for presence of drug, by chemistry analyzers, was paid $1,046,796 over 20 months. That is 86% of this provider's Medicaid dollars. It runs at $78 per patient-month. That ranks at the 88th percentile of all providers billing this code, where the typical figure is $45. records 8
8. 08Code 99213, Established patient office or other outpatient visit with low level od decision making, if using time, 20 minutes or more, was paid $85,117 over 16 months. That is 7% of this provider's Medicaid dollars. It runs at $20 per patient-month. That ranks at the 78th percentile of all providers billing this code, where the typical figure is $44. records 9
9. 09Code 99214, Established patient office or other outpatient visit with moderate level of decision making, if using time, 30 minutes or more, was paid $83,191 over 12 months. That is 7% of this provider's Medicaid dollars. It runs at $117 per patient-month. That ranks at the 98th percentile of all providers billing this code, where the typical figure is $60. records 10
10. 10Code G0481, Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms, was paid $6,046 over 16 months. That is 0% of this provider's Medicaid dollars. It runs at $3 per patient-month. That ranks at the 5th percentile of all providers billing this code, where the typical figure is $98. records 11
11. 11Code G0482, Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms, was paid $2,689 over 13 months. That is 0% of this provider's Medicaid dollars. It runs at $1 per patient-month. That ranks at the 10th percentile of all providers billing this code, where the typical figure is $133. records 12
12. 12Code 99072 was paid $0 over 2 months. That is 0% of this provider's Medicaid dollars. It runs at $0 per patient-month. records 13

Route to the health plan special investigations unit, and to the state Medicaid program integrity unit where the payer is a Medicaid managed care plan, for a records request and a screening check under 42 CFR 455.436. Consider a pre-payment review pending that check; a payment suspension under 42 CFR 455.23 requires the state's own credible-allegation determination. Verify every fact against the cited rows before any action. This packet is a screening product, not a finding.

• A revocation can be reversed on appeal or through a corrective action plan; confirm the current enrollment status with the state and in PECOS before acting.