Attorney General Files Lawsuit against a Network of Pain Management Clinics
Lawsuit alleges $7 million in fraudulent TennCare claims
Attorney General Herbert H. Slatery III today announced the filing of a lawsuit against an organization of pain management clinics owned and operated by Michael Kestner and his business partner, Dr. Lisabeth Williams. Kestner is the primary owner of MMi, which operated at least 18 pain management clinics throughout Tennessee.
The civil action, filed in Williamson County Circuit Court, alleges millions of dollars in fraudulent claims to TennCare dating back to at least 2006.
MMi Pain Clinics and their providers purport to treat people suffering from chronic pain. According to the lawsuit, defendants conducted a fraudulent scheme that involved regularly subjecting patients to unnecessary medical procedures.
“These clinics put profit over patients,” General Slatery said. “Even more disturbing than the millions of dollars in fraudulent claims to the State is their lack of compassion for those coming to them for treatment.”
The most common example is with patients who return each month for a new narcotic prescription. In exchange for the prescription, patients were subjected to superficial back injections known as “trigger-point injections.” Providers typically performed 6-20 injections and in some cases as many as 50 injections per visit. It is not unheard of for a medical provider to perform multiple trigger-point injections in a single patient visit, but never in the volume used by MMi. Regardless of the number of trigger-point injections, billing to TennCare is limited to a single unit per patient for reimbursement.
To circumvent TennCare’s reimbursement policy, the lawsuit alleges MMi billed for trigger point injections as though they were “tendon origin insertions” even if patients were never diagnosed with tendon problems. Tendon injections are commonly used to treat inflammation in tendons of the arms and legs, such as the condition often referred to as tennis elbow. Since there is an expectation that these injections would not be performed in volume, there is not a limit on the number of units allowed for TennCare reimbursement. By calling these injections tendon origin insertions and presenting claims to TennCare with an improper code, MMi providers and defendants were able to subvert – through fraud – the billing limitations on trigger-point injections.
The complaint alleges Mr. Kestner and Dr. Williams, through their providers, knowingly filed false claims for their own personal financial gain. The State estimates for an average TennCare patient visit, MMi received at least six times more in injection reimbursements due to the submission of false claims. Additionally, the State alleges Mr. Kestner coerced MMi providers to perform medically unnecessary injections on their insured patients by rewarding them with financial bonuses or by threatening to fire them if they did not perform more procedures.
The State is seeking an estimated $7 million in damages plus civil penalties, which could triple that amount.