Case 3:22-cv-01091-SI Document 1 Filed 07/27/22 Page 1 of 63
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`
`
`
`
`Heidi L. Mandt, OSB #953459
`hmandt@williamskastner.com
`WILLIAMS, KASTNER & GIBBS PLLC
`1515 SW Fifth Avenue, Suite 600
`Portland, OR 97201-5449
`Phone: (503) 228-7967
`Fax: (503) 222-7261
`Attorneys for Plaintiffs
`
`
`
`UNITED STATES DISTRICT COURT
`DISTRICT OF OREGON
`PORTLAND DIVISION
`
`Case No. 3:22-cv-01091
`
`COMPLAINT
`
`JURY DEMAND REQUESTED
`
`
`GOVERNMENT EMPLOYEES
`INSURANCE COMPANY, GEICO
`INDEMNITY COMPANY, GEICO
`GENERAL INSURANCE COMPANY,
`GEICO CASUALTY COMPANY, and
`GEICO SECURE INSURANCE
`COMPANY,
`
`
`
`
`
`
`Plaintiffs,
`
`v.
`
`KENNY JUNG, L.Ac., SUNNY JUNG, N.D.,
`ACCIDENT PAIN WELLNESS CLINIC,
`INC., and JANE DOE DEFENDANTS 1-2,
`
`
`
`
`Defendant.
`
`
`Plaintiffs Government Employees Insurance Co., GEICO Indemnity Co., GEICO General
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`Insurance Company, GEICO Casualty Co., and GEICO Secure Insurance Company (collectively
`
`“GEICO” or “Plaintiffs”), as and for their Complaint against the Defendants, hereby allege as
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`Page 1 - COMPLAINT
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` 7627471.1
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` Williams Kastner
`1515 SW Fifth Avenue, Suite 600
`Portland, OR 97201-5449
`(503) 228-7967
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`

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`Case 3:22-cv-01091-SI Document 1 Filed 07/27/22 Page 2 of 63
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`follows:
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`INTRODUCTION
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`1.
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`This action seeks to recover more than $300,000.00 that the Defendants
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`wrongfully have obtained from GEICO by submitting, and causing to be submitted thousands of
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`unlawful personal injury protection (“PIP”) insurance charges through Accident Pain Wellness
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`Clinic, Inc. (“Accident Pain Wellness”) for purported initial examinations, acupuncture services,
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`osteopathic manipulation services, and therapeutic services (collectively referred to hereinafter
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`as the “Unlawful Services”).
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`2.
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`The Unlawful Services purportedly were provided to individuals (“Insureds”)
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`who claimed to have been involved in automobile accidents and were eligible for insurance
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`coverage under GEICO automobile insurance policies.
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`3.
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`In addition, GEICO seeks a declaration that GEICO is not legally obligated to pay
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`pending claims submitted or caused to be submitted by the Defendants through Accident Pain
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`Wellness because:
`
`(i)
`
`(ii)
`
`
`(iii)
`
`(iv)
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`the Unlawful Services were not medically necessary, and were provided pursuant
`to pre-determined protocols designed to financially enrich the Defendants, rather
`than to treat or otherwise benefit the Insureds who were subjected to them;
`
`in many cases, the Unlawful Services were never legitimately provided in the first
`instance;
`
`the billing codes used for the Unlawful Services misrepresented and exaggerated
`the level of services that were provided in order to inflate the charges submitted
`to GEICO; and
`
`in many cases, the Unlawful Services were performed – the extent they were
`performed at all – by individuals lacking the requisite licensure to perform those
`services.
`
`
`
`
`
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` 7627471.1
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` Williams Kastner
`1515 SW Fifth Avenue, Suite 600
`Portland, OR 97201-5449
`(503) 228-7967
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`

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`Case 3:22-cv-01091-SI Document 1 Filed 07/27/22 Page 3 of 63
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`4.
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`The Defendants fall into the following categories:
`
`(i)
`
`(ii)
`
`Defendant Kenny Jung, L.Ac. (“K. Jung”) is an acupuncturist licensed to
`practice acupuncture in Oregon, owned and controlled Accident Pain
`Wellness, and performed many of the Unlawful Services.
`
`Defendant Sunny Jung, N.D. (“S. Jung”) is a doctor of naturopathic
`medicine licensed to practice naturopathic medicine in Oregon, owned and
`controlled Accident Pain Wellness, and performed many of the Unlawful
`Services.
`
`(iii) Defendant Accident Pain Wellness is an Oregon corporation through which
`the Unlawful Services purportedly were provided and were billed to
`automobile insurance companies, including GEICO.
`
`Jane Doe Defendants “1” and “2” are unlicensed individuals, presently not
`identifiable, who furthered the unlawful scheme perpetrated against
`GEICO, by, among other things, performing many of the Unlawful
`Services to Insureds without the requisite licenses to do so.
`
`(iv)
`
`
`
`
`
`
`
`5.
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`As discussed below, the Defendants, at all relevant times, have known that:
`
`(i)
`
`(ii)
`
`(iii)
`
`(iv)
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`the Unlawful Services were not medically necessary, and were provided
`pursuant to pre-determined protocols designed to financially enrich the
`Defendants, rather than to treat or otherwise benefit the Insureds who were
`subjected to them;
`
`in many cases, the Unlawful Services were never provided in the first
`instance;
`
`the billing codes used for the Unlawful Services misrepresented and
`exaggerated the level of services that were provided in order to inflate the
`charges submitted to GEICO; and
`
`in many cases, the Unlawful Services were performed – the extent they
`were performed at all – by individuals lacking the requisite licensure to
`perform those services.
`
`6.
`
`As such, the Defendants do not have – and never had – any right to be
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`compensated for the Unlawful Services that they billed or caused to be billed to GEICO. The
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`chart annexed hereto as Exhibit “1” sets forth a large representative sample of the claims that
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` Williams Kastner
`1515 SW Fifth Avenue, Suite 600
`Portland, OR 97201-5449
`(503) 228-7967
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`

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`Case 3:22-cv-01091-SI Document 1 Filed 07/27/22 Page 4 of 63
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`have been identified to date that the Defendants submitted, or caused to be submitted, to GEICO
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`for the Unlawful Services via the United States mail.
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`7.
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`The Defendants’ scheme began as early as 2014 and has continued uninterrupted
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`since that time. As a result of the Defendants’ scheme, GEICO has incurred damages of more
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`than $300,000.00.
`
`I.
`
`Plaintiffs
`
`THE PARTIES
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`8.
`
`Plaintiffs Government Employees Insurance Co., GEICO Indemnity Co., GEICO
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`General Insurance Company, GEICO Casualty Co., and GEICO Secure Insurance Company are
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`Nebraska corporations with their principal places of business in Chevy Chase, Maryland. GEICO
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`is authorized to conduct business and to issue automobile insurance policies in Oregon.
`
`II.
`
`Defendants
`
`9.
`
`Defendant K. Jung resides in and is a citizen of Oregon. K. Jung was licensed to
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`practice acupuncture in Oregon on April 12, 2010, is the president and an owner of Accident Pain
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`Wellness, and performed many of the Unlawful Services.
`
`10.
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`Defendant S. Jung resides in and is a citizen of Oregon. S. Jung was licensed to
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`practice naturopathic medicine in Oregon on October 12, 2016, is the secretary and an owner of
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`Accident Pain Wellness, and performed many of the Unlawful Services.
`
`11.
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`Defendant Accident Pain Wellness is an Oregon corporation with its principal
`
`place of business in Oregon. Accident Pain Wellness was incorporated in Oregon on or about
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`March 3, 2014 and was used by the Defendants as a vehicle to submit unlawful billing to GEICO
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`and other insurers.
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` Williams Kastner
`1515 SW Fifth Avenue, Suite 600
`Portland, OR 97201-5449
`(503) 228-7967
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`

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`Case 3:22-cv-01091-SI Document 1 Filed 07/27/22 Page 5 of 63
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`12.
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`Between March 3, 2014 and February 27, 2017, K. Jung served as the only officer
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`and owner of Accident Pain Wellness. On or about February 27, 2017, S. Jung became secretary
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`and co-owner, with K. Jung, of Accident Pain Wellness.
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`13.
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`Upon information and belief, Jane Doe Defendants 1-2 reside in and are citizens
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`of Oregon. Jane Doe Defendants “1” and “2” are unlicensed individuals, presently not
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`identifiable, who furthered the unlawful scheme perpetrated against GEICO, by, among other
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`things, performing, in part or in whole and in exchange for compensation, Unlawful Services to
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`Insureds without the requisite licenses to do so.
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`JURISDICTION AND VENUE
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`14.
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`This Court has jurisdiction over the subject matter of this action under 28 U.S.C.
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`§ 1332(a)(1) because the total matter in controversy, exclusive of interest and costs, exceeds the
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`jurisdictional threshold of $75,000.00, and is between citizens of different states.
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`15.
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`This Court also has original jurisdiction pursuant to 28 U.S.C. § 1331 over claims
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`brought under 18 U.S.C. §§ 1961 et seq. (the Racketeer Influenced and Corrupt Organizations
`
`(“RICO”) Act).
`
`16.
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`In addition, this Court has supplemental jurisdiction over the subject matter of the
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`claims asserted in this action pursuant to 28 U.S.C. § 1367.
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`17.
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`Venue in this District is appropriate pursuant to 28 U.S.C. § 1391, as the District
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`of Oregon is the District where one or more of the Defendants reside and because this is the
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`District where a substantial amount of the activities forming the basis of the Complaint occurred.
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`/ / /
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` /
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` / /
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`1515 SW Fifth Avenue, Suite 600
`Portland, OR 97201-5449
`(503) 228-7967
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`Case 3:22-cv-01091-SI Document 1 Filed 07/27/22 Page 6 of 63
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`I.
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`ALLEGATIONS
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`An Overview of the Pertinent Law Governing No-Fault Insurance Reimbursement
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`A.
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`18.
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`Oregon’s PIP Law
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`Oregon has a comprehensive statutory system designed to ensure that motor
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`vehicle accident victims are compensated for their injuries. The statutory system is embodied
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`within the Oregon Personal Injury Benefits Law (the “PIP Law”, ORS §§ 742.518-548), which
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`requires automobile insurers to provide Personal Injury Protection Benefits (“PIP Benefits”) to
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`Insureds.
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`19.
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`An Insured can assign his or her right to PIP Benefits to healthcare services
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`providers in exchange for those services. Pursuant to a duly executed assignment, a healthcare
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`services provider may submit claims directly to an insurance company in order to receive
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`payment for medically necessary services.
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`B.
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`No-Fault Reimbursement, Medical Necessity, Misrepresentation, and the
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`Oregon PIP Law
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`20.
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`PIP Benefits required by the PIP Law consist, in relevant part, of the payment of
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`“all reasonable and necessary expenses of medical, hospital, dental, surgical, ambulance, and
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`prosthetic services incurred within two years after the date of the person’s injury, but not more
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`than $15,000 in the aggregate for all such expenses of the person.” ORS § 742.524(1)(a).
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`21.
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`Oregon law allows for an insurer to exclude from coverage for personal injury
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`protection benefits of any injured person who “willfully conceals or misrepresents any material
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`fact in connection with a claim for personal injury benefits.” ORS § 742.530(1)(c).
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`
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`1515 SW Fifth Avenue, Suite 600
`Portland, OR 97201-5449
`(503) 228-7967
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`22.
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`Similarly, ORS § 746.100 prohibits a person from making “false or fraudulent
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`statement[s] or representation[s] on or relative to an application for insurance, or for the purpose
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`of obtaining a fee, commission, money, or benefit from an insurer or insurance provider.”
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`C.
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`23.
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`Pertinent Oregon Law Regarding Medical Billing and Payment
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`Oregon law sets forth a series of prerequisites and requirements for medical
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`billing for and payment of PIP Benefits.
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`24.
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`Under the PIP Law, healthcare services providers are prohibited from billing for
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`services in amounts in excess of the lesser of: (i) the amount the provider charges the general
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`public; or (ii) the amount set forth in the fee schedules for medical services published pursuant
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`to Oregon’s worker’s compensation statutes (the “Fee Schedule”). See ORS § 742.525.
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`25. Moreover, the Oregon Director of the Department of Consumer and Business
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`Services has promulgated a series of rules governing medical billing pursuant to the Fee
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`Schedule.
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`26.
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`In particular, Oregon law permits reimbursement for healthcare billing only for
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`“treatment that falls within the scope and field of the medical provider’s license to practice….”
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`See OAR § 436-009-0010(1)(a).
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`27. What is more, OAR § 436-009-0010(1)(d) prohibits medical providers from
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`submitting “false or fraudulent billings, including billing for services not provided.” “False or
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`fraudulent” is defined as “an intentional deception or misrepresentation with the knowledge that
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`the deception could result in unauthorized benefit to the provider or some other person.” Id.
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`28. Medical providers must submit bills on a completed current Centers for Medicare
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`& Medicaid Services (“CMS”) 1450 or CMS 1500 form. See OAR § 436-009-0010(3)(b).
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`1515 SW Fifth Avenue, Suite 600
`Portland, OR 97201-5449
`(503) 228-7967
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`Case 3:22-cv-01091-SI Document 1 Filed 07/27/22 Page 8 of 63
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`29.
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`Subject to limited exceptions not relevant here, medical providers are required to
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`complete their CMS 1450 or 1500 forms in accordance with the instructions provided in the
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`National Uniform Claim Committee 1500 Claim Form Reference Instruction Manual. See OAR
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`§ 436-009-0010(3)(c).
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`30. When billing for medical services, a medical provider must use current procedural
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`terminology (“CPT”) promulgated by the American Medical Association.
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`31.
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`The Fee Schedule adopts, by reference, the American Medical Association’s CPT
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`Assistant (“CPT Assistant”) and the alphanumeric codes from the Centers for Medicare &
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`Medicaid Services (“CMS”) Healthcare Common Procedure Coding System (HCPCS).
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`32.
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`If there is no specific code for the medical service, the medical provider must use
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`the “unlisted” code and provide a description of the service provided.
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`33. Moreover, Oregon law requires that medical provider billings must be
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`accompanied by legible chart notes that, among other things, must document the services that
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`have been billed and identify the person performing the service. See OAR § 436-009-0010(7)(a-
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`b).
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`D.
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`34.
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`Pertinent Oregon Law Governing the Practice of Acupuncture
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`Oregon law defines acupuncture as an “Oriental health care practice used to
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`promote health and to treat neurological, organic, or function disorders by the stimulation of
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`specific points on the surface of the body by the insertion of needles”, which includes “the
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`treatment method of moxibustion, as well as the use of electrical, thermal, mechanical, or
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`magnetic devices, with or without needles, to stimulate acupuncture points and acupuncture
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`meridians to induce acupuncture anesthesia or analgesia.” See O.A.R. 847-070-0005(1)(a).
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`1515 SW Fifth Avenue, Suite 600
`Portland, OR 97201-5449
`(503) 228-7967
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`Case 3:22-cv-01091-SI Document 1 Filed 07/27/22 Page 9 of 63
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`35.
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`In addition, the practice of acupuncture is defined to include “Oriental massage,
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`exercise, and related therapeutic methods”. See O.A.R. 847-070-0005(1)(b)(B).
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`36.
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`In Oregon, only individuals licensed by the Oregon Medical Board to practice
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`acupuncture, along with licensed physicians, are permitted to administer acupuncture treatment
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`to any other individual. See O.A.R. 847-070-0020(1).
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`II.
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`The Defendants’ Unlawful Treatment and Billing Protocol
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`37.
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`Beginning in 2014, the Defendants carried out a scheme whereby they billed
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`GEICO hundreds of thousands of dollars for medically unnecessary and illusory services.
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`38.
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`In the claims identified in Exhibit “1”, the vast majority of the Insureds whom the
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`Defendants purported to treat did not suffer from any significant injuries or health problems at
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`all as a result of the accidents they experienced or purported to experience.
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`39.
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`Even so, the Defendants purported to subject many Insureds to a medically
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`unnecessary course of “treatment” that was provided pursuant to a pre-determined protocol
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`designed to maximize the billing that the Defendants could submit or cause to be submitted to
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`insurers, including GEICO, rather than to treat or otherwise benefit the Insureds who purportedly
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`were subjected to it.
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`40.
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`The Defendants provided their pre-determined treatment protocol to Insureds
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`without regard for the Insureds’ individual symptoms or presentment, or – in most cases – the
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`total absence of any serious medical problems arising from any actual automobile accidents.
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`41.
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`The Defendants permitted the unlawful treatment and billing protocol described
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`below to proceed under their auspices because the Defendants sought to profit from the unlawful
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`billing submitted to GEICO and other insurers.
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`Page 9 - COMPLAINT
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`1515 SW Fifth Avenue, Suite 600
`Portland, OR 97201-5449
`(503) 228-7967
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`Case 3:22-cv-01091-SI Document 1 Filed 07/27/22 Page 10 of 63
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`A.
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`42.
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`The Unlawful Charges for Initial Examinations at Accident Pain Wellness
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`As an initial step in their unlawful treatment and billing protocol, Accident Pain
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`Wellness, K. Jung, and S. Jung provided virtually every insured in the claims identified in Exhibit
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`“1” with an initial examination.
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`43.
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`As set forth in Exhibit “1”, K. Jung and S. Jung performed the majority of the
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`initial examinations at Accident Pain Wellness, which were then primarily billed to GEICO under
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`CPT code 99203.
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`44.
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`In the claims for initial examinations identified in Exhibit “1”, the charges for the
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`initial examinations were unlawful in that they misrepresented the nature and extent of the
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`examinations, as well as whether the examinations were ever legitimately provided in the first
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`instance.
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`1.
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`Misrepresentations Regarding
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`the Severity of
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`the Insureds’
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`Presenting Problems
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`45.
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`In the claims for initial examinations under CPT code 99203 identified in Exhibit
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`“1”, Accident Pain Wellness, K. Jung, and S. Jung routinely misrepresented the severity of the
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`Insureds’ presenting problems.
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`46.
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`Pursuant to the American Medical Association’s CPT Assistant, the use of CPT
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`code 99203 to bill for an initial patient examination typically requires that the Insured present
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`with problems of moderate severity.
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`47.
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`The CPT Assistant also provides various clinical examples of the types of
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`presenting problems that qualify as moderately severe, and thereby justify the use of CPT codes
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`99203 to bill for an initial patient examination.
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`1515 SW Fifth Avenue, Suite 600
`Portland, OR 97201-5449
`(503) 228-7967
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`Case 3:22-cv-01091-SI Document 1 Filed 07/27/22 Page 11 of 63
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`48.
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`For example, the CPT Assistant provides the following clinical examples of
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`presenting problems that might support the use of CPT code 99203 to bill for an initial patient
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`examination:
`
`(i)
`
`(ii)
`
`
`(iii)
`
`
`(iv)
`
`
`(v)
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`Office visit for initial evaluation of a 48-year-old man with recurrent low back
`pain radiating to the leg. (General Surgery)
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`Initial office evaluation of 49-year-old male with nasal obstruction. Detailed exam
`with topical anesthesia. (Plastic Surgery)
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`Initial office evaluation for diagnosis and management of painless gross
`hematuria in new patient, without cystoscopy. (Internal Medicine)
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`Initial office visit for evaluation of 13-year-old female with progressive scoliosis.
`(Physical Medicine and Rehabilitation)
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`Initial office visit with couple for counseling concerning voluntary vasectomy for
`sterility. Spent 30 minutes discussing procedure, risks and benefits, and answering
`questions. (Urology)
`
`49.
`
`Thus, pursuant to the CPT Assistant, the moderately severe presenting problems
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`
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`that could support the use of CPT code 99203 to bill for an initial patient examination typically
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`are either chronic and relatively serious problems, acute problems requiring immediate invasive
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`treatment, or issues that legitimately require physician counseling.
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`50.
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`By contrast, to the extent that the Insureds in the claims identified in Exhibit “1”
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`had any presenting problems at all as the result of their automobile accidents, the problems
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`virtually always of low or minimal severity.
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`51.
`
`In keeping with the fact that the Insureds in the claims identified in Exhibit “1”
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`presented with problems of low or minimal severity, to the limited extent that the Insureds did
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`report to a hospital after their accidents, they virtually always were briefly observed on an
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`outpatient basis and then sent on their way after a few hours with, at most, a minor sprain or
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`1515 SW Fifth Avenue, Suite 600
`Portland, OR 97201-5449
`(503) 228-7967
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`Case 3:22-cv-01091-SI Document 1 Filed 07/27/22 Page 12 of 63
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`strain diagnosis and/or similar soft-tissue injuries.
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`52.
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`Even so, in the claims for initial examinations identified in Exhibit “1”, Accident
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`Pain Wellness, K. Jung, and S. Jung routinely billed for their initial examinations using CPT code
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`99203, and thereby falsely represented that the Insureds presented with problems of moderate
`
`For example:
`
`On February 7, 2015, an Insured named AW was involved in an automobile
`accident. In keeping with the fact that AW was not seriously injured, AW did not
`visit any hospital emergency room following the accident. To the extent that AW
`experienced any health problems at all as a result of the accident, they were of
`low or minimal severity. Even so, following a purported initial examination of
`AW on March 26, 2015, K. Jung and Accident Pain Wellness billed GEICO for
`the initial examination using CPT code 99203, and thereby falsely represented
`that the initial examination involved presenting problems of moderate severity.
`
`On November 18, 2015, an Insured named WJ was involved in an automobile
`accident. The contemporaneous police report indicated that the accident was a
`low-speed, low-impact collision, that the damage to WJ’s vehicle was minor, and
`that WJ’s vehicle was drivable following the accident. The police report further
`indicated that WJ was transported by ambulance to Providence St. Vincent
`Medical Center. The contemporaneous hospital records indicated that WJ was
`briefly observed on an outpatient basis, and was discharged the same day with a
`minor cervical strain and chest contusion diagnosis. To the extent that WJ
`experienced any health problems at all as a result of the accident, they were of
`low or minimal severity. Even so, following a purported initial examination of WJ
`on November 19, 2015, K. Jung and Accident Pain Wellness billed GEICO for
`the initial examination using CPT code 99203, and thereby falsely represented
`that the initial examination involved presenting problems of moderate severity.
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`severity.
`
`53.
`
`(i)
`
`(ii)
`
`
`
`
`
`(iii) On May 20, 2016, an Insured named YK was involved in an automobile accident.
`In keeping with the fact that YK was not seriously injured, YK did not visit any
`hospital emergency room following the accident. To the extent that YK
`experienced any health problems at all as a result of the accident, they were of
`low or minimal severity. Even so, following a purported initial examination of
`YK on May 23, 2016, K. Jung and Accident Pain Wellness billed GEICO for the
`initial examination using CPT code 99203, and thereby falsely represented that
`the initial examination involved presenting problems of moderate severity.
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`1515 SW Fifth Avenue, Suite 600
`Portland, OR 97201-5449
`(503) 228-7967
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`Case 3:22-cv-01091-SI Document 1 Filed 07/27/22 Page 13 of 63
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`(iv) On March 30, 2018, an Insured named HH was involved in an automobile
`accident. In keeping with the fact that HH was not seriously injured, HH did not
`visit any hospital emergency room following the accident. To the extent that HH
`experienced any health problems at all as a result of the accident, they were of
`low or minimal severity. Even so, following a purported initial examination of
`HH on March 30, 2018, K. Jung, S. Jung, and Accident Pain Wellness billed
`GEICO for the initial examination using CPT code 99203, and thereby falsely
`represented that the initial examination involved presenting problems of moderate
`severity.
`
`
`(v)
`
`On April 10, 2019, an Insured named MS was involved in an automobile accident.
`In keeping with the fact that MS was not seriously injured, MS did not visit any
`hospital emergency room following the accident. To the extent that MS
`experienced any health problems at all as a result of the accident, they were of
`low or minimal severity. Even so, following a purported initial examination of
`MS on May 20, 2019, K. Jung, S. Jung, and Accident Pain Wellness billed GEICO
`for the initial examination using CPT code 99203, and thereby falsely represented
`that the initial examination involved presenting problems of moderate severity.
`
`54.
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`These are only representative examples. In virtually all of the claims for initial
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`examinations identified in Exhibit “1”, Accident Pain Wellness, K. Jung, and S. Jung falsely
`
`represented that Insureds presented with problems of moderate severity, when in fact that
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`Insureds’ problems were low or minimal severity soft tissue injuries such as sprains and strains,
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`to the extent that they had any presenting problems at all at the time of the examinations.
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`55.
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`In the claims for initial examinations identified in Exhibit “1”, Accident Pain
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`Wellness, K. Jung, and S. Jung routinely falsely represented that the Insureds presented with
`
`problems of moderate or moderate severity in order to create a false basis for their charges for
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`the examinations under CPT code 99203, because examinations billable under CPT code 99203
`
`are reimbursable at a higher rate than examinations involving presenting problems of low,
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`minimal, or no severity.
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`56.
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`In the claims for initial examinations identified in Exhibit “1”, Accident Pain
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`Wellness, K. Jung, and S. Jung also routinely falsely represented that the Insureds presented with
`
`Page 13 - COMPLAINT
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` Williams Kastner
`1515 SW Fifth Avenue, Suite 600
`Portland, OR 97201-5449
`(503) 228-7967
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`Case 3:22-cv-01091-SI Document 1 Filed 07/27/22 Page 14 of 63
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`problems of moderate severity in order to create a false basis for the other Unlawful Services that
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`the Defendants provided to the Insureds.
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`2.
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`Misrepresentations Regarding the Amount of Time Spent on the
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`Purported Examinations
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`57. Moreover, the use of CPT code 99203 to bill for an initial examination represents
`
`that the physician, naturopath, or acupuncturist who performed the examination spent at least 30
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`minutes of face-to-face time with the patient or the patient’s family.
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`58.
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`As set forth in Exhibit “1”, Accident Pain Wellness, K. Jung, and S. Jung
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`submitted many of their bills for initial examinations under CPT code 99203, and thereby
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`represented that they performed the initial examinations and purported to spend 30 minutes of
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`face-to-face time with the Insureds or the Insureds’ families during the examinations.
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`59.
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`In fact, in the claims for initial examinations identified in Exhibit “1”, neither K.
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`Jung, S. Jung, or any other physician, acupuncturist, or naturopath associated with Accident Pain
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`Wellness ever spent 30 minutes of face-to-face time with the Insureds or their families when
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`conducting the examinations and consultations.
`
`60.
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`Rather, in the claims for initial examinations identified in Exhibit “1”, the initial
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`examinations did not entail more than 15 minutes of face-to-face time between the examining
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`physician, acupuncturist, or naturopath, and the Insureds or their families, to the extent that the
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`examinations actually were performed in the first instance.
`
`61.
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`For instance, and in keeping with the fact that the initial examinations allegedly
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`provided by K. Jung, S. Jung, and Accident Pain Wellness did not entail more than 15 minutes
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`of face-to-face time with the insureds or their families, K. Jung and S. Jung used template forms
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`Page 14 - COMPLAINT
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`1515 SW Fifth Avenue, Suite 600
`Portland, OR 97201-5449
`(503) 228-7967
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`

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`Case 3:22-cv-01091-SI Document 1 Filed 07/27/22 Page 15 of 63
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`in purporting to conduct the initial examinations.
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`62.
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`The template forms that K. Jung and S. Jung used to document the examinations
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`set forth a very limited range of potential patient complaints, examination/diagnostic testing
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`options, potential diagnoses, and treatment recommendations.
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`63.
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`All that was required to complete the template forms was a brief patient interview
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`and a brief physical examination of the Insureds’ musculoskeletal system, consisting, at most, of
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`a check of some of the Insureds’ vital signs, basic range of motion and muscle strength testing,
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`and other basic forms of testing.
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`64.
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`These interviews and examinations did not require any acupuncturist, naturopath,
`
`or any other healthcare provider associated with Associated Pain & Wellness to spend more than
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`15 minutes of face-to-face time with the Insureds during the initial examinations.
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`65.
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`In the claims for initial examinations identified in Exhibit “1”, Accident Pain
`
`Wellness falsely represented that the examinations and consultations involved 30 minutes of
`
`face-to-face time with the Insureds or their families in order to create a false basis for their
`
`charges under CPT code 99203 because examinations and consultations billable under CPT code
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`99203 is reimbursable at a higher rate than examinations and consultations that require less time
`
`to perform.
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`3.
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`Misrepresentations Regarding “Detailed” Examinations
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`66. Moreover, in the claims identified in Exhibit “1” for examinations under CPT
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`code 99203, Accident Pain Wellness, K. Jung, and S. Jung falsely represented the extent of the
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`underlying physical examinations.
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`Page 15 - COMPLAINT
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` 7627471.1
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` Williams Kastner
`1515 SW Fifth Avenue, Suite 600
`Portland, OR 97201-5449
`(503) 228-7967
`
`

`

`Case 3:22-cv-01091-SI Document 1 Filed 07/27/22 Page 16 of 63
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`67.
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`Pursuant to the CPT Assistant, the use of CPT code 99203 to bill for a patient
`
`examination represents that the naturopath or acupuncturist who performed the examination
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`conducted a “detailed” physical examination.
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`68.
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`As set forth in Exhibit “1”, Accident Pain Wellness, K. Jung, and S. Jung virtually
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`always billed for the initial examinations using CPT code 99203, and thereby represented that K.
`
`Jung and S. Jung conducted detailed physical examinations of the Insureds who purportedly
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`received the examinations.
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`69.
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`Pursuant to the CPT Assistant, a “detailed” physical examination requires –
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`among other things – that the acupuncturist or naturopath conduct an extended examination of
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`the affected body areas and other symptomatic or related organ systems.
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`70.
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`Pursuant to the CPT Assistant, in the context of patient examinations, an
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`acupuncturist or naturopath has not conducted an extended examination of a patient’s
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`musculoskeletal organ system unless the acupuncturist or naturopath has documented findings
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`with respect to the following:
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`measurement of any three of the following seven vital signs: (a) sitting or standing
`blood pressure; (b) supine blood pressure; (c) pulse rate and regularity; (d)
`respiration; (e) temperature; (f) height; (g) weight;
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`general appearance of patient (e.g., development, nutrition, body habitus,
`deformities, attention to grooming);
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`examination of peripheral vascular system by observation (e.g., swelling,
`varicosities) and palpation (e.g., pulses, temperature, edema, tenderness);
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`palpation of lymph nodes in neck, axillae, groin and/or other location;
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`brief assessment of mental status;
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`examination of gait and station;
`
`(i)
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`(ii)
`
`
`(iii)
`
`
`(iv)
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`(v)
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`(vi)
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`Page 16 - COMPLAINT
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` 7627471.1
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` Williams Kastner
`1515 SW Fifth Avenue, Suite 600
`Portland, OR 97201-5449
`(503) 228-7967
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`Case 3:22-cv-01091-SI Document 1 Filed 07/27/22 Page 17 of 63
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`(vii)
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`inspection and/or palpation of skin and subcutaneous tissue (e.g., scars, rashes,
`lesions, café au-lait spots, ulcers) in four of the following six areas: (a) head and
`neck; (b) trunk; (c) right upper extremity; (d) left upper extremity; (e) right lower
`extremity; and (f) left lower extremity;
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`
`(viii) coordination;
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`(ix)
`
`
`(x)
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`71.
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`examination of deep tendon reflexes and/or nerve stretch test with notation of
`pathological reflexes; and
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`examination of sensation.
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`In the claims for initial examinations identified in Exhibit “1”, when Accident
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`Pain Wellness, K. Jung, and S. J