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NY based billing company billing for NJ Provider?

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KarenH:
Here's the deal, if you have any knowledge and you should if you are doing medical billing if you suspect a problem and do nothing to correct it and just bill it you're liable. It's not simple data entry as many people like to believe. Example some of my clients are DME suppliers and HH suppliers; if I am getting prescriptions which I require in order to bill and they are all in the same handwriting you better bet that there is a problem. If you get a response that it was a verbal order all verbal orders you have a problem. You have to challenge that plain and simple, you need that documentation from the MD or the prescribing entity if you don't have it or it looks like the same handwriting and you bill it you're at fault and are going to end up because odds are that they are fraudulently billing. You need to warn terminate and report it. I've unfortunately had to do this on a few occasions. One excuse was from a home health supplier who had a nurse on staff and she said I know what they need I don't bother the doctors, guess what they are no longer in business got sanctioned and I protected myself and my other clients from being audited. The OIG will tell you ignorance is no excuse. I can go on but you better pay attention make sure that your providers are not constantly billing a high level of E/M you need to question that, things like that are all red flags for audits and you're compliant as a business associate. If you decide you don't believe Linda go to the OIG site and see who has been busted lately.

PMRNC:
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.
--- Quote ---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!!!!!!
--- End quote ---

Yes, I must have created the LEGAL verbiage used in the False claims act right?



--- Quote ---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.
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"One of the Practices"   you mean billing company right?? Seriously you are completely IGNORANT. If you did your research and you looked at previous references even here on this forum in the archives you would see that I MAKE it a point to point out that it is NOT ILLEGAL for a billing company to charge a % of collections, It is ILLEGAL for the provider to engage in fee-splitting arrangements in those said states (NY is one).   I will be sure to tell my own attorney he's full of it ok? How about I quote him and you provide some contact information?       And let's again clarify some more mis information... BY YOUR OWN WORDS in posts I've quoted you landed your FIRST account in Nov of 2012.  So you mean to tell me ONE of your accounts you took over between Nov and NOW already went through this lawsuit? What county are you in that happens so fast?  And let's say your not full of crap... what does the contractual relationship between the biller and doctor have to do with their suit?  Do you really think the provider's attorney will bring up that fact in court which would ONLY negate the contract (that means to make null/void) If the contractual relationship was not a part of the suit it bares no mention in court case as vague as one you mention. 


--- Quote ---You would think that the judge would know if it's allowed or not.
--- End quote ---


LOL   first.. do you know why courts have judges?   Ahem..    if it is not privy to the case, why would it matter? Your BS phony case has NO details of what the lawsuit was about!!


--- Quote ---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.
--- End quote ---

Oh if it's a done deal it would be public record. Case mention please?  Since this is an account you "took over" did you take over for the biller, billing company (you see you never make that distinction)?   What was your place in said case?
The fee-splitting issue and this issue are NOT related. One has nothing to do with the other unless either party enters the contract into the court record.   Can we have this case precedent information?   Without details of this case it's NOT cut/dry on the issue.  I have maintained that billers/billing companies are NOT responsible for errors made by a provider in regards to their files. We are NOT required to bill using the patient documentation in their medical record at all. WE are however responsible for the MANY errors that occur that we SHOULD catch that are obvious.  IF you know it's wrong, it's an error, and you do what you are advising others to do and shut up and bill it anyway, you have then created a "false claim" .  PERIOD.  Just because your provider says it's ok to go ahead or to ignore something doesn't mean it's ok for you to do it when you KNOW it's wrong. Why do you think they use the word "KNOWINGLY".   A mistake / error can indeed turn into a false claim if you proceed to submit it KNOWING it's incorrect.   Are you seriously still going to dispute that?    "Yes your honor, I knew it was wrong but he told me to do it anyway"..  In all honesty is that what you would say ??   

PMRNC:

--- Quote ---Here's the deal, if you have any knowledge and you should if you are doing medical billing if you suspect a problem and do nothing to correct it and just bill it you're liable. It's not simple data entry as many people like to believe.
--- End quote ---


Exactly.... Gayle seems to be under the impression that if her doctor says "eh, bill it anyway" he's the boss, she's free and clear of liability. The fact that she IS responsible if she bills something KNOWING it's incorrect IS the liability.   


--- Quote ---If you decide you don't believe Linda go to the OIG site and see who has been busted lately.
--- End quote ---

She obviously does not do her research as she's exposed herself as a phony by her own words/posts.  Sure, I guess it's possible she obtained her VERY first account (her words) in Nov of 2012 and then took over an account that went through a lawsuit already.  Not likely though. 

RichardP:
Yes your honor, I knew it was wrong but he told me to do it anyway"..  In all honesty is that what you would say ??

I am impressed with the responses here.  Those just starting out are going to get a comprehensive education if they read all the way through this thread.  Thank you all taking the time to respond.

Your responses all the way through this thread emphasize what should be emphasized.  Billers should give a damn about what they are doing, and know the laws and regulations as much as they can.  However, I will stand by my original couple of points.

1.  Can anyone provide a link to a situation where a billing entity was taken to court and found guilty of any charge other than for billing charges that the doctor did not ask them to bill?

2.  Can anyone provide a link to a situation where a billing entity was taken to court and found guilty of the charge of billing what the doctor told them to bill (per the quote from Linda at the top of this post)?

3.  Based on what I have been able to find (and I realize I haven't found everything), the biggest risk to the biller is billing for charges that cannot be found in the patient's chart.  If I can't guarantee that changes are going to be placed into the chart when I bill for them, I'm not going to bill for the changes.  That is not just an ethical consideration, it is a legal one as well, because I can be prosecuted.

4.  The second biggest risk to billers is being found guilty of collusion with a doctor with the intention of defrauding the paying party.  Again, this is not just an ethical consideration, because I can be prosecuted if I am proved guilty of collaboration with the intent to defraud.

5.  The category that seems to be in contention here is what risk there is to a biller who has no intention to defraud when they bill only for what the doctor gives them.  The main point of this category is the question asked of the biller by the court in the quote from Linda at the top of this post:  Did you know it was wrong?

With all due respect, I think that is a red herring.  The court has no interest in proving what a biller knows.  They only have an interest in proving collusion with intent to defraud.  The only way a biller will be found guilty by the court is if it is proved that the biller colluded with the doctor in an attempt to defraud a paying party.

6.  There is no legal requirement for a biller to check the patient's chart before billing for the charges the doctor gives them.  The biller is allowed to rely on the expertise of the doctor, and it is the doctor that will be held legally responsible if anything is amiss.  There may be an ethical obligation for the biller to refuse and/or resign if the doctor is intentionally asking the biller to bill falsely, and the biller knows it.  But there is not a legal obligation.  The doctor will be held liable in this case, not the biller - assuming that the court finds no evidence that the biller intended to collaborate with the doctor to defraud a payer.  The OIG statement that the suggestion to resign in such a case does not carry a legal obligation to do so, it is just a recommendation, bears this out.

For Linda to imply that a "yes" answer to the question "did you know it was wrong" will result in a penalty for the biller is misleading.  (What can the court do to you if your ethics allow you to answer no to that question?)  The only thing that will result in a penalty for the biller is if the court proves that the biller colluded with the doctor in an attempt to defraud the paying party.

Again, if I am wrong, provide links to the results of court cases that show a biller was found guilty when the court did not prove the biller was guilty of collusion with intent to defraud.  (I'm not asking for links to cases where the biller was found guilty of billing for charges the doctor did not give him.  That is a separate legal issue.)

PMRNC:

--- Quote ---1.  Can anyone provide a link to a situation where a billing entity was taken to court and found guilty of any charge other than for billing charges that the doctor did not ask them to bill?
--- End quote ---

This is what we were talking about. I said nothing about a biller going ahead and billing things a doctor did Not tell them or instruct them to bill. That indeed would be fraud, I don't need to look up a case precedence on that do you really?  If I go ahead and bill a claim I was not given or instructed to file, I've submitted a false claim, have I not? Do you really need a case precedent for this.. I'd be happy to research but I think you'll see my point as I was in NO way saying we bill things not instructed to bill at all.


--- Quote ---2.  Can anyone provide a link to a situation where a billing entity was taken to court and found guilty of the charge of billing what the doctor told them to bill (per the quote from Linda at the top of this post)?
--- End quote ---

Again, what are you looking for?  you say "found guilty of the charge of billing what the doctor told them to bill"  What is the charge? Is the charge "billing" if so we would all be in court. Are you looking for cases where a biller billed something they KNEW or SHOULD have known was false?  I just want to be clear on what your looking for before scouring cases.  I do find it perplexing no one wants to address the case she stated or the obvious Bull crap associated with it! No one wants her to cite that case to which she says "a lawsuit" with a "practice" and biller was right? Never-mind it all happened in less than 3 months. We'll just skip over that right?    Anyway.. what specifically are you looking for? 


--- Quote ---3.  Based on what I have been able to find (and I realize I haven't found everything), the biggest risk to the biller is billing for charges that cannot be found in the patient's chart.  If I can't guarantee that changes are going to be placed into the chart when I bill for them, I'm not going to bill for the changes.  That is not just an ethical consideration, it is a legal one as well, because I can be prosecuted.
--- End quote ---

So your saying it's ok if biller submits a claim coded for a cast on the arm when you know it was the leg?  Are you saying it's ok to bill a circumcision on a baby girl (don't laugh because as a claims examiner I have seen MANY bills for baby girls being charged for a circumcision)  Indeed those are "errors" under most circumstances but once WHOMEVER catches that error BEFORE it's sent and does NOT correct it, it then most certainly becomes a false claim.  Your implying no one would get caught if claiming ignorance.. ?  It is indeed MY liability if I am sending a claim I know is incorrect.


--- Quote ---4.  The second biggest risk to billers is being found guilty of collusion with a doctor with the intention of defrauding the paying party.  Again, this is not just an ethical consideration, because I can be prosecuted if I am proved guilty of collaboration with the intent to defraud.
--- End quote ---
 

My own attorney has told me that proving "intent" is not always a precedent for a guilty outcome. Even looking at liability policies you will see that there is verbiage to allow for the exclusion of ignorance when proving fraud/abuse.   In the legal world things are not so cut/dry or black/white. 


--- Quote ---5.  The category that seems to be in contention here is what risk there is to a biller who has no intention to defraud when they bill only for what the doctor gives them.  The main point of this category is the question asked of the biller by the court in the quote from Linda at the top of this post:  Did you know it was wrong?

With all due respect, I think that is a red herring.  The court has no interest in proving what a biller knows. They only have an interest in proving collusion with intent to defraud.  The only way a biller will be found guilty by the court is if it is proved that the biller colluded with the doctor in an attempt to defraud a paying party.
--- End quote ---

Richard that's correct, the court cannot determine what the biller KNEW, but they can interpret what they SHOULD have known doing the job to which they are supposed to be trained to do.  Again I refer you to the false claims act which does include verbiage to say "SHOULD have known".  A physician SHOULD have known you don't leave a scalpel in a patient as much as a biller should know you don't bill for a circumcision on a baby girl.    A biller SHOULD know that if she is aware Mrs. Smith cancelled her appointment but Dr. Smith already had her slip made out in advance (no/no) they shouldn't bill it even if Dr. Smith says, Oh so what, bill it anyway.  A biller cannot always use "I didn't know" in cases where they "SHOULD have known".   Certainly if the biller did NOT know Mrs. Smith didn't come in, she is off the hook. Let's suppose Mrs. Smith gets her EOB and calls and says "But I wasn't there that day".   Biller says "oh well too bad, no big deal you don't owe us the insurance company paid" We will just write off your copay.  NO.. the correct procedure is to alert the provider with the benefit of the doubt that indeed a mistake was made.. where it goes from there becomes libelous to both the biller and the doctor. The doctor if he ignores the error and the biller if she/he goes along with it.


--- Quote ---6.  There is no legal requirement for a biller to check the patient's chart before billing for the charges the doctor gives them.  The biller is allowed to rely on the expertise of the doctor, and it is the doctor that will be held legally responsible if anything is amiss.  There may be an ethical obligation for the biller to refuse and/or resign if the doctor is intentionally asking the biller to bill falsely, and the biller knows it.  But there is not a legal obligation.  The doctor will be held liable in this case, not the biller - assuming that the court finds no evidence that the biller intended to collaborate with the doctor to defraud a payer.  The OIG statement that the suggestion to resign in such a case does not carry a legal obligation to do so, it is just a recommendation, bears this out.
--- End quote ---

Re read my posts.. I have stated over and over I agree about not having to check patient's chart. Bottom line is that there are Literally MANY many errors that are billed in error OBLIVIOUS to the record and not NEEDING the record to catch. That is not wrong, that's a mistake, an error, however if NOTHING gets done to correct the error and the biller KNOWS it's erroneous that's where the trouble is.


--- Quote ---For Linda to imply that a "yes" answer to the question "did you know it was wrong" will result in a penalty for the biller is misleading.  (What can the court do to you if your ethics allow you to answer no to that question?)  The only thing that will result in a penalty for the biller is if the court proves that the biller colluded with the doctor in an attempt to defraud the paying party.
--- End quote ---

For you to imply there is no liability if they answer "yes" they knew it was wrong is misleading as well. You are indeed saying it's ok to bill something you know is wrong because that's your job to bill what your given to bill, not question it or fix any errors found.. did I understand that correctly?  I can't say what would happen in a court room if a biller admits to sending a claim(s) that they knew was wrong, incorrect, fraudulent, etc.  because so many factors exist. INTENT can be shown if there is knowledge that the biller KNEW of the false claim or error in which they did nothing to correct it. (that came from my attorney)


--- Quote ---Again, if I am wrong, provide links to the results of court cases that show a biller was found guilty when the court did not prove the biller was guilty of collusion with intent to defraud.  (I'm not asking for links to cases where the biller was found guilty of billing for charges the doctor did not give him.  That is a separate legal issue.)
--- End quote ---

Richard do you realize the splitting hairs of any legal case? showing a biller was found guilty if court did not prove biller was guilty of collusion with intent to defraud"  Is incredibly vague.. What are we talking about here? If something GOES to court like this to begin with I'm sure it's not a matter of "oh I knew the code was wrong on that claim but I submitted it anyway".   To make it that far in court you would have to agree there's a bit more involved dontcha think?  So before I go looking for cases, be more specific on what you need to be shown.   TO me I don't have to be shown that it's MY job to KNOW certain things right off the bat, forget the chart, it's MY job to spot, correct or attempt to correct errors and NOT file them and turn it into a false claim. If that does not make me libel, I need to rethink paying my lawyer and my Errors & Omissions insurance.  My policy does NOT cover my ass for knowingly submitting a false claim BTW.

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