General Category > General Questions
NY based billing company billing for NJ Provider?
galinafl26:
Dekenn, She is confused on a lot of things and simply giving the wrong information to people who are starting out just like she was going on and on about the biller being responsible for what the doctor is billing! She is saying nonsense and calling other people ignorant! Like seriously? who's ignorant here??
Richard P. wrote and excellent response to her to which she didn't even bother replying to because unlike her, Richard had real laws backing up his information. She goes on and on and about having compliance plans, and how she know everything when by far a lot of her information is not true. She's more concerned about compliance plans thinking she's going to Wow the doctor by saying she has a compliance plan and that % is not allowed in their state. I mean come on!!!!!!
The funny part of this all, is that one of the practices that I took over in NY, where according to Linda % billing is not allowed, went through a lawsuit. They TRIED to sue the biller stating the biller wasen't billing whatever they were told to bill therefore it resulted in insurance audit and overpayment. Blah, blah, blah.. First of all, no one even mentioned the fact that % billing wasen't allowed in NY. You would think that the judge would know if it's allowed or not. The word % billing did not even come up. That's first, second of all, the biller had proof that whatever was given to him to bill on a superbill was billed out on a daily basis. The biller kept all superbills and provided evidence in court that he was billing whatever was given to him by the doctor. As Richard stated, there's no law stating that the biller is supposed to check notes to make sure the doctor is billing the correct codes. And guess what happened in court?? The biller was found not guilty and as per the judge, his exact words were "you are the doctor, you need to know what is going on in your practice, you cannot blame the biller for billing what you gave him to bill" Case close! Done deal! The doctor should know better to document properly.
galinafl26:
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.
Exactly my point, I don't care for opinions, I want court opinions! And Linda simply has NONE. She started a facebook page asking people about opinions?? Who are these people? Why do I need their opinion as if I am going to trust some other biller?? If you can show me a court opinion, I will believe it, otherwise don't bother ranting on about things that are simply false or simply say I DONT KNOW!!!
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.
YOU ARE NOT AWARE OF ANY BECAUSE THEY DONT EXIST. We are not SUPPOSED TO GO THROUGH CHARTS to make sure charges are correct.
I welcome links to any court cases where the decision contradicts what I have said here.
PMRNC:
--- Quote ---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.
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Richard, that was not the impression her post gave to me.
--- Quote ---Richard, I understand what you are saying.... some billers do that and some don't. I have a doctor in New York who I tried to give him that advice and he kindly asked me to never tell him any advice and how to do things, he's set on his old way and he wants to do things the way he is used to saying so in this case, it is a data entry account, where he only wants me to bill whatever he writes on the super bill.
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If I had a client whom I know was doing something wrong, coding something wrong, and I submitted anyway, I am JUST as libel. The False Claims Act is very clear in saying "ANYONE WHO KNOWINGLY.....
" § 3729. False claims
(a) Liability for certain acts.
(1) In general. Subject to paragraph (2), any person who--
(A) knowingly presents, or causes to be presented, a false or fraudulent claim for payment or approval;............
(b) Definitions. For purposes of this section--
(1) the terms "knowing" and "knowingly"--
(A) mean that a person, with respect to information--
(i) has actual knowledge of the information;
(ii) acts in deliberate ignorance of the truth or falsity of the information; or
(iii) acts in reckless disregard of the truth or falsity of the information; and
(B) require no proof of specific intent to defraud;
[/color]
Bottom line, if she found an error, provider refused to change said error she became libel because she knew of it. Same applied in my situation. ONCE I knew my client who was to oversee his biofeedback technician ON SITE was actually 2000 miles away, and the technician was sending me daysheets, had I billed it I WOULD have been libel because I did so "Knowingly" Now I don't know how that could not be more CLEAR.
--- Quote ---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.
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You don't even need the OIG guidelines in this debate. I also want to mention that in May of 2009 the False claim Act added amendments under the "Fraud Enforcement and Recovery Act of 2009." that directly impact a third party medical billing company:
The amendment: Extended the whistleblower protection provisions to cover both "contractors" and "agents" in addition to employees who allege that they were subjected to retaliation when they tried to put an end to False Claims Act violations by their employer. From a practical standpoint, third-party billers have often been considered to be "contractors" and "agents" of health care providers, rather than merely employees in support of operations. Prior to the recent amendments, the whistleblower provisions only typically applied to actual employees of the health care provider. Now, both "contractors" and "agents" may avail themselves of the Act's whistleblower protections.
The amendment also revised the definition of "obligation" to expressly include knowingly retaining mere over payments despite the fact that a CMHC may have accidentally been overpaid. This change is extraordinarily important. Third-party billing companies may now find themselves liable under the False Claims Act, regardless of whether the overpayment was caused as a result of a mistake caused by the provider or by a government contractor, such as a MAC. This presents significant exposure for billers who knowingly fail to promptly return the funds. Your billing company may now find itself subject to liability under the False Claims Act, including its penalty and damages provisions even though the overpayment innocently occurred. Example: Insurance company overpays on a claim. Biller imputs and sees there is a credit. She advises the provider and the provider tells her "don't worry about it" leave it alone. The credit sits there. If the patient nor insurance company never claim it then who cares right? WRONG. BILLER is just as responsible for that overpayment and not reporting it. THE proper procedure would have been for the biller to send back the check if it was noticed immediately before the check was deposited with an explanation or letter to the carrier. IF the check was already deposited and the overpayment was discovered later, certainly the biller has no obligation to cut a check, however they can (and should) still report the overpayment to the carrier. NOT doing so now makes the biller or person who knows of the overpayment JUST as libel.
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. I acknowledge that. I am speaking of "liability" not guilt or lack there of, that's for court to determine.
There is no legislation 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. Again, I am not saying we are to be mind readers. I am speaking of errors or acts that make the biller aware of right away that it is wrong or incorrect. Example: Patient comes in for a follow up after surgery, charge slip contains an E/M code, biller knows OR EVEN SHOULD KNOW, because again IGNORANCE is not allowed here, that the visit was to be included with the surgical procedure. Now that she KNOWS this, she brings it to the attention of the doctor and if he is not receptive to correction the biller, IF they send that claim and do what galinafl26 strongly implied by shutting up, putting the claim in the system and sending the claim because that's what the doctor wants her to do". She has KNOWINGLY submitted a false claim. PERIOD. Certainly deficiencies in the record that we as billers are not privy to become only the responsibility of the physician. galinafl26 left a very strong impression that we shut up and bill what is in front of us, and I'm sorry, I'm not going to agree with that. Why on earth would we need Liability or Quai Tam? We are not merely "employee's" nor are we "Data Entry Clerks"
The OIG DID submit GUIDELINES for compliance in regards to the federal false claims act and OTHER enforced regulations, as well as advice in setting a "plan of compliance". This doesn't mean just because OIG made these recommendations it made up laws as it went along.
Let me give you another example. I took over the billing for a pediatric practice who served a big portion of the Jewish community, Their office manager and biller had left the office abruptly and I was told it was because they were insubordinate..(should have been my first clue but I was wet behind the ear). In order to get him to where I would not have to be in the office I had to go and convert his office from an old paper system to an automated one. He was older, set in his ways, so it was a great challenge to say the least. On my 2nd day there a family came in, there were 3 children. The office became quite busy that day and I had wondered what I had gotten myself into. By the time this family went in with the doctor (which I thought odd he seen the whole family in one room) the waiting room was quite busy with approximately 18-20 other people in there. When he came out, he came out with 6 fee slips. Now when I worked as a claims rep in the fraud dept of an insurance company this type of fraud was VERY common so I knew what was going on when I seen the fee slips and it pertained both English name and Hebrew name. It became pretty clear what was going on and upon pulling fee slips I had not entered yet from the day before I found the SAME thing occurring in more than half the visits from the previous day. At the end of that day I went into his office and confronted him. He told me point blank that was reason he fired his office manager and biller/receptionist because they could not "follow directions". Some big blessings in this for me was that I KNEW from previously working on the other side what type of fraud was going on. Later on, because my mom had known the office manager for years we found out he had been caught previously and she was told she could be held responsible, so from that day forward she refused to submit the claims/fee slips and he fired her along with the biller/receptionist. Had I been uneducated, un experienced and came to this forum and read what galinafl26 had to say I would certainly feel better because, hey it wasn't' my neck! But I would have been wrong and I would have found myself in hot water. I don't tell that story about that pediatrician because of a few reasons, one is that regrettably I did not turn him in, though someone else did later and he was sanctioned.
--- Quote ---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.
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Richard that assumes that all billers mainly use paper/documentation to find such errors or document such errors. The procedures I take to maintain the compliance of MY office do not reply merely on a paper trail in the matter in which you think. Are you aware that upon audit the number one thing looked at first is the ACTUAL and physical appointment book? Physician groups advise physician this is one source document they should NOT get rid of. There are also audit trails in PM software and in MY business I have my own source of documentation of such errors, discussions with my clients. Some would call it my "diary" At the beginning of my day this very large red notebook is on my desk, at the end of the day it's locked away with the rest of my work, my family teases me about my "diary". My attorney advised me to make that so-called diary procedure entering as part of my compliance plan, it's my go to book. Last week I advised my provider that he needed to correct a daysheet that mistakenly had a psych testing code to which he mixed up with another testing code, I will not process that charge until he sends it back corrected. I know it's a wrong code because of the way he labeled it on his daysheet. Since he labeled it wrong (description) it was obvious, had he not and I billed it then I would not be responsible, as I would have no way to know it was incorrect. Providers moving to EHR's will make up their own minds of whether to go fully paper or not. The mandatory EHR is only going to affect those providers who bill govt healthcare plans and even then it does NOT prevent them from discontinuing their paper documentation. I know a LOT of doctors not thrilled with the EHR solution and don't trust it. I myself have had a problem with a private physician with mine and my daughters medical record to which my attorney drew up a an "opt out". Physicians will need to have procedures to handle such patient requests as the patient will not be forced to comply with a risky and imperfect system that could compromise their privacy. As I've stated before I have no more clients in Medicare or Medicaid. I have 2 providers that have an EHR in place but still utilize certain documentation procedures due to their own mistrust of the system. I have another client who is testing an EHR and so far isn't impressed. It was just recent announced in our local paper that one of our largest outpatient clinics in our area has decided to get out of Medicare and Medicaid as well. I'm getting off topic but did want to address that we can mandate a move to EHR but you won't get the majority of physicians/providers to just ditch their pen and paper.
--- Quote ---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.
--- End quote ---
But your again not accounting for obvious errors (coding or otherwise) that CAN be picked up w/out the paper trail Richard, that's what I'm talking about. AS billers we are REQUIRED to know certain things. We are supposed to KNOW and SPOT something as it appears. If you are billing for a chiropractor and your chiropractor coded something obviously wrong, doing NOTHING makes you responsible.. EHR or not. An oversight, a mistake can be an oversight and mistake but when caught and NOT dealt with it then becomes a false claim.
I also pointed out several things about galinafl26 that made me disagree.. if you go back to previous posts of hers you will find many discrepancies.. her first account in Nov of 2012, ok, maybe she had experience elsewhere before starting her own business. Her stand that she bills what she's told to bill contradicts this previous post from Last month:
http://www.medicalbillinglive.com/members/index.php?topic=6995.msg20701#msg20701
--- Quote --- HI I AM BILLING FOR AN OBGYN AND HE PERFORMED TOTAL ABDOMINAL HYSTERECTOMY (58150) AND ALSO EXPLATORY LAPAROSCOPY (59000) HOW DO I BILL THEM TOGETHER AND GET PAID FOR BOTH. WHAT MODIFIER WOULD I ADD?
HE ALSO DID AN INITIAL HOSPITAL EXAM (99222)
THANKS EVERYONE!
GAYLE
--- End quote ---
Or this one:
http://www.medicalbillinglive.com/members/index.php?topic=6985.msg20687#msg20687
--- Quote ---my contract also states that I collect a percentage of full practice revenue however this particular doctor doesn't go crazy collection copayment or deductibles. Again, I can't get my question answered. Do I run an aging report based on whatever was posting to invoice my doctor?
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http://www.medicalbillinglive.com/members/index.php?topic=6950.msg20407#msg20407
--- Quote ---Hello everyone. I am trying to find out different ways and the best ways to advertise your billing company. I just moved to Florida from New York and looking for best ways to advertise to physicians. I mostly do Ob/gyn billing. I was thinking maybe going to an Ob/Gyn conference and setting up a booth. Does anyone know what works the best?
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Why I bring these up is because if you look she clearly states she knows more, knows the laws, and flat out tells me I'm wrong because she is more experienced. Is it fair to allow that in a forum where people come to learn NOT be misled? It is indeed misleading billers into thinking they are free of liability and that we just do data entry. CLEARLY she missed the facts about it being illegal in NY and FLORIDA for a provider to enter into a fee-splitting arrangement didn't she?
PMRNC:
--- Quote ---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.
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I have consulted with 18 attorney's overall split between the states that have fee-splitting laws, I will give reference to one here in Florida.
"Over the past 10 years, the Florida Board of Medicine has issued a number of declaratory statements on the subject of fee splitting in the context of employment, management, and marketing arrangements between licensed physicians and business corporations and partnerships. The board’s early declaratory statements addressed less than comprehensive business arrangements when private companies provided only space and basic management services. The board’s most recent declaratory statement addresses overall management and marketing as provided by current physician practice management companies (PPMs). PPMs integrate physician practices into well organized networks for, among other things, the purposes of obtaining managed care contracts with health management organizations, insurers, and employers and of taking advantage of economies of scale.
At a meeting in Tampa on October 17, 1997, the board made its most recent statement on the issue of fee splitting related to medical practice management. In its final order filed on November 10, 1997, the board declared that a management contract between Access Medical, Inc., a 15-physician internal medicine group, and a practice management company, Management Company, Inc., violates Florida’s statutory prohibition on fee splitting.1 The management contract, described in the petition for declaratory statement, requires the group to pay Phymatrix a percentage of the group’s net revenues, in addition to all actual operating costs and a flat fee of $450,000 per year. In return, Phymatrix provides management services to the group that include physician network development, managed care contracting, and other efforts to increase the number of patient referrals made to the group. Phymatrix is appealing the board’s final order and the board has agreed to stay the final order pending the outcome of the appeal.2 The decision has attracted substantial attention at the state and national levels, as it threatens the legality of the current popular trend toward similar management contracts between physician practice groups and PPMs.[/u]
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. . . .”3
SHARING IN THE REVENUES OF A PHYSICIAN OR HEALTHCARE PROVIDER IS Fee splitting.
I've spent years researching this one issue and cited many cases/case precedences as well as documentation from attorney's in regards to this. It's important to note that this is NOT saying the billing company is committing a crime by charge a percentage of collections. The laws that prohibit fee-splitting arrangments are in regards to state licensing and medical ethics which prohibits the PHYSICIAN from engaging in fee-splitting arrangements.. WHATSOEVER
PMRNC:
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.
Gayle ORIGINALLY posted how she was confused because she is an "S" Corp, which was in response to a post and answers regarding required third pary medical billing companies needing to be registered in some states (NJ is one of them). NO where did we mention NJ and fee splitting. I'm not sure what this has to do with any of the 5 topics here.
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