Fruad Billing

[ChristineS]

If I am doing a consult for a provider and I find that he is fruadulantly billing dont i have to report it?? or do you tell them how to correct the problem and it is up to them?

i have not come across this problem before...

[Pay_My_Claims]

its sticky, because you become liable if you bill something you know isn't correct. what you should do is let the physician know that you can't bill this code to insurance and justify the reason.

[thatcuteblonde]

A few more questions in regards to fraud (in the state of Illinois, primarily Medicare) ;
1. Is it lawful to bill under a Chiropractor who is not on the premesis and is ill for services rendered by other Chiropractors?

2. Is it legal to bill P/T to Medicare without a licensed P/T on staff F/T supervising?

3. Is an anesthesiologist a substitue for licensed P/T? i.e. can a company bill physical therapy services under an M.D. who is only certified in ansethesiology?

4. Can an anethesiologist act as a practicing M.D./Pain Mangement doc, even though he was not certified as one, has no experience in an office setting and write out prescriptions to patients like a GP or Pain Mgmt doc can?

Any info is helpful! Thx!

[Michele]

1. Is it lawful to bill under a Chiropractor who is not on the premesis and is ill for services rendered by other Chiropractors?     No, it is not ok to bill for one dr's services under another dr's name

2. Is it legal to bill P/T to Medicare without a licensed P/T on staff F/T supervising?  Who is providing the PT?  The services must be provided by an approved Medicare provider that PT is within their scope of practice.  Medicare has very specific laws on PT.


3. Is an anesthesiologist a substitue for licensed P/T? i.e. can a company bill physical therapy services under an M.D. who is only certified in ansethesiology?
I'm alittle confused by the question.  I have never heard of an anesthesiologist doing PT, and I've heard of some crazy things.  If the provider is a Medicare provider and is enrolled with his/her specialty as anesthesiology, medicare will not reimburse PT codes.
4. Can an anethesiologist act as a practicing M.D./Pain Mangement doc, even though he was not certified as one, has no experience in an office setting and write out prescriptions to patients like a GP or Pain Mgmt doc can?There are many anesthesiologists who specialize in pain management, but they  are credentialed with the insurance carriers as such.  Different carriers have different requirements for credentialing, but it varies by carrier.  Again, if the provider is enrolled in Medicare it will depend on how they enrolled (what specialty they listed).


Hope that helps.

Michele

[PMRNC]

Just the mere "Suspicion" of fraud/abuse scares me and it should scare you. YES if you knowingly suspect or have billed services that are fraudulant you ARE required to report them. Refer to your compliance plan for guidance as that's what it's there for. Hopefully you have one. When I suspect fraud, I will confront the provider and depending on the incident, it is documented and the provider is terminated ASAP, NO NOTICE because once I suspect or know.. I am libel. There is no wiggle room at all. My compliance plan is clear and precise on the procedure for this. Your questions alone are a bit scary to me and if I were you.. i would stop researching because it just about sounds like you KNOW something is fishy.. you are not here to play "is this legal..." that's an attorney's job. Your job is that if you "suspect" and then KNOWINGLY bill it you are libel. Also there is a clause in the federal statutes on fraud and abuse that "Not knowing" can be just as dangerous. As the biller you are required to know if something is right or not.