Author Topic: false claims act  (Read 1627 times)

margemib

  • Full Member
  • ***
  • Posts: 210
false claims act
« on: June 29, 2010, 01:37:07 PM »
I have heard somewhere that because of healthcare reform, under the false claims act the 3rd party billers will be more responsible then ever for any false claims.
I was thinking if a biller is filing just claims only and and not the PM and you are not working in the doctors office it is hard to know what is going on.
That would not be fair if you are responsible for someone else, that is out of your control.
any comments on this matter?
margemib
Margie Finlay CMRS

oneround

  • Full Member
  • ***
  • Posts: 227
Re: false claims act
« Reply #1 on: June 29, 2010, 06:15:00 PM »
Margemib.  The responsibility of all involved in correct billing and coding in the new False Claims Act has not made all more responsible then what had been amended before The Patient Protection and Affordable Care Act passed in March 2010 makes key changes to the FCA’s public disclosure bar, the treatment of exchange payments and overpayments, and enforcement of the Anti-Kickback Statute. These changes come on the heels of the 2009 FCA amendments it now exposes ALL providers to potential civil and criminal liability, fines, and exclusion from the Medicare program. It's really geared at helping providers understand the rapidly expanding liability risks under the FCA and develop policies to ensure compliance and mitigate risks of FCA violations and whistleblower actions.

Most of the Key changes to False Claims Act in Health Reform Law are things as Public disclosure bar and original source exception
Exchange payments
Overpayments
Kickbacks
Best practices for minimizing liability exposure
Effective compliance program
Personnel training
Voluntary disclosure to government
Defending accuracy and truthfulness of submitted information
Benefits

It's my belief in reviewing the bill that it's not meant as a finger pointing tactic but more of a "Hey, tighten' up because this could get serious if you don't play by the rules!"  When discussing this with my peers this is not a topic of concern for many of us because many of us have been following this plan all along.

Incorrect billing happens everyday no matter what facility or office you are with.  Falsely submitted a claim for payment and making an inadvertent billing. Coding error are two different things.  Inadvertent billing usually involves only a warning with mention of correcting the mistake, knowingly and falsely coding and billing on the other hand usually has no leniency.
Michael A. Reynolds, CPC, CCP-P, CPMB, OS
Project Manager
Corporate Compliance
Sharp HealthCare

margemib

  • Full Member
  • ***
  • Posts: 210
Re: false claims act
« Reply #2 on: June 29, 2010, 07:54:29 PM »
what I am saying is that if you are not in control of the info sent to a biller, how do you know if for instance say the insurance company over paid the provider and you have no control over wether or not the credit was given back to the ins co, I heard that the biller is responsable just because you sent the claim out and are part of the billing process.
margemib
Margie Finlay CMRS

PMRNC

  • Hero Member
  • *****
  • Posts: 4218
    • One Stop Resources & Networking for Medical Billers
Re: false claims act
« Reply #3 on: June 30, 2010, 10:05:19 AM »
That's nothing new, but as for your "liability" ONCE you KNOW of such an act, it's your responsibility to take action .. in other words "Don't just look the other way" of course you cannot cut the check to reimburse the provider.. so what you do is go to your compliance guidelines, mine would tell me to advise the provider IN WRITING and document and save the procedure you take. With that action you have CYA. If it continues however you then have another problem to which you would be libel to report such actions.  Once you sit a provider down and explain this usually they will follow suit, if they don't then bottom line is you need to protect YOURSELF. DOCUMENT all conversations and all written directives to your client/provider so that in case you need it you just didn't sit back and do anything.  But yes legally you would be JUST as libel as the provider if you did nothing to correct the problem.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

Alice Scott

  • Global Moderator
  • Full Member
  • *****
  • Posts: 209
    • Solutions Medical Billing
Re: false claims act
« Reply #4 on: June 30, 2010, 10:44:09 AM »
Hi Marge,
Long story - should be a chapter in one of our books - not a post BUT - good lesson -

Many years ago we were contacted by the fraud unit of BC asking for an appointment to come out and visit us.  They came and told us they are investigating one of our providers we had been billing for several years.  BC wanted to know how we received the info from the provider and what we did with it.  Then they wanted copies of all the records.

Well, we had never actually met this provider even though she lived only one half hour away.  We did everything by phone, fax and mail.  She called us daily with a list of patients she saw that day and mailed us eobs.  We told her that we couldn't take her list of people over the phone and she would have to fax them to us.  She gave us every excuse in the book.  Her fax didn't work, the pages came out blank, this was much easier than faxing.  It was early in our career and we didn't want to lose a good account so we bought a stenographers notebook and kept a record of all her calls in the notebook.  We wrote down everything she told us - people she saw and comments on eobs or problems.  Well we got to about 5 stenographers pads by the time BC came knocking.  

The rep from BC told us that we could have been looked at as responsible for any billing errors as the provider was but because we were willing to cooperate and had complete records of everything that happened between us over those several years that they had no problem with us.  They told us that prosecutors were very reluctant to go after insurance fraud but they pursued this vehemently.  


As it turned out, this provider wasn't seeing the patients.  The one patient we met in the courthouse on the first beautiful day of that spring had gone to her once but received eobs from BC for many more visits.  We spent that lovely day in court testifying.  

My point is, keep good records.  Don't accept notification of visits over the phone.  And don't work with providers you think are committing fraud.  (We really had no idea she wasn't seeing the patients.)  The insurance companies aren't out to see if you made a mistake on a claim.  They are looking for outright thieves.






Sign Up for our FREE Medical Billing Newsletter
Get a 10% discount on Medical Billing Products by using Coupon Code: 10OFF
http://www.solutions-medical-billing.com

Pay_My_Claims

  • Guest
Re: false claims act
« Reply #5 on: June 30, 2010, 12:43:39 PM »
great advice

margemib

  • Full Member
  • ***
  • Posts: 210
Re: false claims act
« Reply #6 on: June 30, 2010, 01:53:20 PM »
Thanks for the advice.
Margie Finlay CMRS