General Category > General Questions
NY based billing company billing for NJ Provider?
galinafl26:
Yes, I do a lot of cheap doctors billing! At least I don't have doctor's who are doing fraud and I don't have to worry about dropping a dr! I'll stick to cheap over someone who does fraud. Thank you.
RichardP:
[edit] I see that several other comments have posted while I was typing this. Those new comments are not addressed in what is written below - but it appears I covered some of the same issues that are raised in the new comments. [/edit]
In the back and forth, a number of different issues have been raised. Bear with me for a moment. You are both dancing around an issue that I have with EMRs and Practice Management Systems - the lack of a paper trail for audit purposes. Consider this scenario I faced when asked to use G.E.'s Centricity system. It is a totally paperless system, and the EMR can pass billing info to the PM side electronically - but there is no way to return the electronic fee slip back to the EMR from the PM.
Doctor is diligent and puts all relevant info into EMR. Signs off (which locks that DOS) and forwards the electronic fee slip to the PM side. Biller receives the electronic fee slip and sees that some codes are wrong and need to be changed, and some other codes are missing and need to be added. Biller cannot return the electronic fee slip to the EMR. Doctor cannot go back into DOS for that patient and make the necessary changes. So, what does the biller do? Puts in a call to the doctor. Doctor calls back while driving home after work. "Yeah, change the wrong codes to the correct codes, and add the codes I forgot to put on the electronic fee slip. I'll add an addendum to the patients account in the morning." Biller makes the changes the doctor authorized and sends the data off to the clearinghouse. Doctor forgets to add the addendum to the DOS for that patient. Account gets audited at some later time. And there is the stark evidence: biller billed for things that cannot be supported by the data in the patient's electronic chart in the EMR. Fraud. Biller is found guilty and hung out to dry.
It was on this basis I turned down the doctor's group that was using Centricity. There is no way to protect the biller from the situation I just described. Now, consider what we do with our current setup, using the same criteria as above.
Doctor is diligent and checks off all relevant codes on the paper fee slip. Sends paper fee slip to us. We receive the paper fee slip and see that some codes are wrong and need to be changed, and some other codes are missing and need to be added. We return paper fee slip to doctor, with our comments attached. At his leisure, doctor makes the necessary changes and returns the paper fee slip to us. We type the codes into the PM system and send it off to the clearinghouse. We return the paper fee slip, with the doctors changes written on it in his handwriting, to the doctor, who puts it into the patients chart. Account gets audited at some later time. And there is the stark evidence: the only things biller billed for are things that can be supported by the data in the patient's chart. No fraud. Biller passes the audit.
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With regards to the posts above:
1. galinafla26 said only that she had one client who resisted her efforts to educate him. So she left him alone. I did not see where she stated that she does not provide feedback to any of her clients.
2. The OIG has guidelines for billing companies. In those guidelines, the OIG states that the guidelines do not carry the force of law. They are only recommendations. And in those guidelines is the recommendation for a biller to dismiss a client when the biller knows that the client is billing fraudulently. Since that recommendation does not carry the force of law, it suggests that billers cannot be legally held liable for following a doctor's direction to bill fraudulently. If any one can provide links to cases that refute this, I would be interested in seeing them. I don't want someone's opinion. I want court opinion, if it exists.
3. When lawsuits are filed, as many entities are named in the lawsuit as can be. Being named in a lawsuit is no guarantee that any judgement is going to go against the named party. A lawsuit against a doctor can also name the biller as a defendant. That does not mean the biller will be found guilty of anything.
4. I am not aware of any state regulation that requires a biller to go through the patient's chart and make certain that all charges the doctor has given them to bill are supported by the information in the chart. The biller can only bill what the doctor gives them. Therefore, without a requirement that the biller verify that all charges are supported by the chart, any difficiencies are the responsibility of the doctor, not the biller - regardless of who is named in the lawsuit. It cannot possibly be any other way.
5. Where a biller can be held legally liable is in the case of fraud - where the biller has submitted for payment charges that the doctor did not give them. In Point 4 above, the biller cannot be held liable for deficiencies if all he has done is bill what the doctor gave him - for the reason stated there. In this Point 5, the biller can be held liable for deficiencies that arise when they bill for things the doctor did not give them - because they are billing for charges that the doctor did not give them. That is the distinction between these two Points 4 & 5 - the distinction between when a biller can be held liable and all other times when he will not be held liable.
I welcome links to any court cases where the decision contradicts what I have said here.
6. As we move towards the paperless office of electronic data collection and billing, we are losing the very valuable paper audit trail. Since the most likely case for billers being prosecuted is billing for charges the doctor did not give them, and since the scenario I presented above with Centricity is a very real situation right now, and is getting worse - I see the paperless office as shutting the mouths of those billers who wish to educate their doctors on how to legally bill for all monies they possibly can. There is just too much chance with electronic billing that the changes the doctor authorizes will not/can not be added to the patient's electronic chart - which leaves the biller open to the one thing they can be prosecuted for with no questions asked: billing for charges that cannot be found in the patient's chart for that date of service.
In a paperless office setting, where it is impossible to leave a paper audit trail, the only way to guarantee that this scenario won't happen is to say nothing back to the doctor and bill only for what he gives us - no matter how deficient the coding from the doctor may be. That scenario is not useful to anybody.
galinafl26:
Richard, you couldn't of said it better!!! I wish everyone understood this! This is exactly what I was talking about. They are goin on and on about billet being liable and I ve been saying all along what you just said. Bravo!!!!!!!!!
dekenn:
Florida Statute:
The basis for the final order appears in F.S. 458.331(1), which sets forth a list of acts or omissions for which the board may take disciplinary action against a physician's license. The list includes 458.331(1)(i), which prohibits "paying or receiving any commission,
bonus, kickback, or rebate, or engaging in any split-fee arrangement in any form whatsoever with a physician, organization, agency, or person, either directly or indirectly, for patients referred to providers of health care goods and services . . ."This is an article From the Florida State Bar in regards to Illegal fee splitting and cites a perfect example.
This refers to a physician "splitting a fee", or giving kickbacks to someone else for referring patients to him. This doesn't sound like it has anything to do with paying for services on a percentage basis, as long as the biller is not referring him the patients. Fee splitting does not necessarily mean the same as being paid on a percentage basis.
dekenn:
Found this on the internet, in relation to payment to billing services:
This is from the laws regarding payment and billing of EMS Services in Mount Laurel Township, which is in New Jersey:
http://ecode360.com/12597358
"The professional medical billing service shall be responsible for the initial billing and two follow-up billings. Costs associated with the professional medical billing service shall be based solely on a percent of reimbursement collections as provided in its contract with the Township of Mount Laurel. "
I would imagine that the attorneys for the Township know the laws about "percentage of collections" and "fee-splitting". Linda, I think you're confused about what "fee-splitting" really means.
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