Spotting fraud in plain sight — when medical records tell a story that never happened.

For years, I believed my pain management care was honest and thorough. But after reviewing a full copy of my medical records on the patient portal, I uncovered a pattern of deception that points to serious concerns—including Medicare fraud, upcoding, and potentially unethical billing.

Every visit I attended was recorded in medical records as having a detailed physical exam, yet no one was actually performed this practice that could be classified as Medicare Fraud. The notes were copied nearly word for word across different providers over a span of four years. Diagnoses listed in these records didn’t match my true medical history, and none of the supposed evaluations were backed by tests. No stethoscope was used. No genuine physical assessment occurred.

Eventually, a physician assistant admitted the truth: exams weren’t conducted, but staff were expected to document them anyway. Why? Most likely to support billing at inflated levels like CPT code 99214—a practice known as upcoding. This tactic boosts reimbursement without delivering the care that code demands.

Once I raised ethical concerns to the practice directly, I was dismissed as a patient. The practice stated I needed a lowTHC card from the state. I did the paperwork, gave it to the physician since the physician help was the only way to obtain the card. They refused to help and proceeded to test me the last three appointments which they knew I would fail. Their justification? My legal use of low-THC CBD, despite meeting the state’s criteria for a medical card.  But the discharge is okay, my primary care physician found me a better practice to take its place.

When I formally requested all my medical records to include` billing records, lab results, and appointment notes via certified mail, the response was incomplete—twice. After 30 days passed with only partial documents, I filed a 36-page complaint with the Office of Inspector General (OIG). I also noticed additions in my final three visit records, stating “patient requested no physical exam.” Practice used CPT code 99214 for less than 5 minutes, but Code 99214 is to be used for 30-39 minutes. This filling CPT code 99214 for a visit of less than 5 minutes visit clearly in my view could be Medicare fraud.

This experience showed me how easily fraudulent documentation, kickback incentives, and noncompliant coding can be hidden in plain sight. And how difficult it is for patients to get the truth.

Has This Happened to You? Tell Your Story

If you’ve experienced:

• Suspicious billing practices
• Retaliation after speaking up
• Denial of legitimate treatments
• Medical records are not correct
• Medicare fraud
  —you’re not alone.

You don’t need to name names or places. Just share what happened. –your story will be respected and protected. Please use the comment section to share your experience.

Helpful Links:

• Report Medicare fraud to the OIG
• CPT Coding Guidelines from AMA
• Medicare Fraud & Abuse: Prevent, Detect, Report