General Category > General Questions
Fraud and Abuse - Coda
RichardP:
Linda, I have no disagreement in general with what you say. I do think it is important for prospective and new billers to understand that things will not always be black and white. The bane of adult living is that we often are forced to make choices in the absense of perfect information. Erring on the side of caution is a commendable behavior. My larger point is - what do you do when in a situation where you don't know on which side caution lies? That was intended only as a "heads up" in passing. I didn't mean for it to become it's own subject of debate.
The following points about the two links you provided are intended only as follow-up and are not intended as fodder for further debate:
Linda, in the first link you gave, the charges covered the period from / the relevant conduct took place between approximately July 1991 and September 1997. That period of time could not have been defined unless someone actually looked at the coding and then at the charts to see if the record supported the coding (court and billers are not supposed to make up charges out of thin air). They obviously found that the record did not support the coding at least between those two dates. The period of time was long enough, and the data points of discrepancy between chart and coding were numerous enough, that the court could conclude the occurance of the discrepancy was greater than chance. Therefore, if not chance, then intentional. Intentional = intent. The court did find intent in your example.
Re. the second link you gave: In the closed thread, I stated that I was exluding from my discussion those cases where the biller was intentionally billing charges for procedures that the doctor did not perform. This is obviously illegal, and is also obviously the fault of the biller alone. There would be no question of guilt on the part of the doctor, because he did not perform the procedures, and he did not supply the codes, that the biller billed for. Linda, the case re. Delgado, Solis, and Rael fits into this category - and is therefore not suitable for using to debate any points that I made. I specifically excluded this category of illegal behavior from what I was discussing, because it is so obvious who the guilty party is. A quick scan through the opening paragraphs at this link will demonstrate that Delgado was intentionally billing for services the doctor did not provide. Also, please note that all involved were found guilty, doctors and biller.
ftp://opinions.ca5.uscourts.gov/byDate/Jan2012/Jan19/10-50726-CR0.wpd.pdf
From this and other evidence, the jury could readily infer her criminal intent to commit
healthcare fraud and make false statements relating to health care matters.
(bottom of Page 7)
http://www.namfcu.net/resources/medicaid-fraud-reports-newsletters/2010-publications/10JulyAug.pdf [see Page 21]
Attorney General Abbott announced on July 27 that Sylvia Delgado was sentenced in federal court to 51 months incarceration and three years supervised release and Robert Rael was sentenced to 24 months and three years of supervised release. They were ordered to pay $1.4 million in restitution to the Medicaid and Medicare programs. Dr. Solis and Delgado were found guilty in September 2009 of providing false statements relating to health care matters and Delgado was also found guilty of health care fraud and conspiracy to commit health care fraud. Robert Rael pleaded guilty to two felony counts in September 2007. (See: Medicaid Fraud Report, September/October 2009, pg.2).
gary999:
Very interesting read.
I have a question concerning a client. We do not code. We never enter anything other what is given us. If something obviously wrong we do bill it. We do NOT bill Medicare patients for non-cover services without an ABN. We charge a % of collections which is OK in our state. I employee 30 or so billing clerks who report to 2 supervisors who report to a manager.
What is my exposure for a client who sends us mostly level 5 visits? The client is a neurological sub-specialist with a low volume of patients. We have never seen a medical record. When we have a request for records we send the insurance form to the practice (at their request) and they attach the record and send to the carrier.
Thank for your responses in advance.
Edited to add NOT
PMRNC:
THE best person to ask that would be an attorney. I'm just going to refrain from any type of legal advice all-together. FOR me taking MY attorney's advice works for me because it's the safest and surest way to keep my butt out of trouble. I also do carry proper E/O (Quai Tam) insurance as an added layer. I take the position that if I KNOW there's something not right and I bill it anyway, I'm libel because I know of the error/fraud/abuse. I have a special "out" clause in my contract that states I can terminate a contract WITHOUT notice if I suspect any fraud/abuse or if a client is unwilling to make corrections where they need to be corrected. If I receive a charge to bill out and I spot an error or problem from the information I Receive, I give the provider the charge back and according to my own compliance plan the procedure is that the provider makes the change, initials it and documents his own records as well with the correction. This is how I roll :)
DO consult your own attorney or legal counsel to give yourself the assurance you need. Also make sure you really look at your E/O policies, and compliance plan as well as any policies/procedures you have in place. Because you have employee's its imperative (LOOK Richard, I didn't say Legal) to have a good compliance plan and policies procedures so you are all on the same page.
RichardP:
Edit: Linda - you posted as I was typing this. We are on the same page. /Edit
Gary - you need to have any legal questions answered by a health-care attorney who is familiar with the regulations of your state. This link will help you find one if you don't already have one.
http://lawyers.findlaw.com/lawyer/practice/health-health-care-law
Do you receive codes from your clients electronically, or do you receive them on paper and have your clerks type them into your billing system? Those logistics are going to govern what you can do, never mind what you should do. I turned down a client who uses G.E.s Centricity system for several reasons - and a major reason was this: the EMR part of that system sends codes electronically to the PM part with no way for the billers to send the codes back to the EMR part for corrections.
You said: If something obviously wrong we do bill it.
Wrong, as in incorrect (e.g., OB/Gyn codes for a heart procedure)? Or wrong, as in illegal?
You said: We do bill Medicare patients for non-cover services without an ABN.
Some relevant points to keep in mind. It is the doctor's responsibility, not yours, to use the ABN when necessary. The biller is not required to examine the patients chart before billing to see if it contains support for the codes submitted to you by the doctor. If you are receiving codes electronically, how can the ABN be included?
You said: What is my exposure for a client who sends us mostly level 5 visits?
What do you mean by exposure? Do you mean, can you be held legally liable for overuse of the Level 5 code? That would be a question for your health care attorney to answer specifically. But generally, do you have specific knowledge that your client is billing Level 5 for visits that are not Level 5? If your answer is yes, then I would strongly urge you to get a response from your health care attorney.
If you are interested in further information, you might Google on "Level 5 visits". That will get you to links such as these two:
http://www.medicalbillingandcoding.org/blog/leveling-up-to-level-5-visits-part-1-of-2-99205-coding-and-compliance/
http://www.physicianspractice.com/level-5-part-ii
gary999:
--- Quote from: RichardP on February 09, 2013, 12:58:35 PM ---Edit: Linda - you posted as I was typing this. We are on the same page. /Edit
Gary - you need to have any legal questions answered by a health-care attorney who is familiar with the regulations of your state. This link will help you find one if you don't already have one.
http://lawyers.findlaw.com/lawyer/practice/health-health-care-law
Do you receive codes from your clients electronically, or do you receive them on paper and have your clerks type them into your billing system? Those logistics are going to govern what you can do, never mind what you should do. I turned down a client who uses G.E.s Centricity system for several reasons - and a major reason was this: the EMR part of that system sends codes electronically to the PM part with no way for the billers to send the codes back to the EMR part for corrections.
You said: If something obviously wrong we do bill it.
Wrong, as in incorrect (e.g., OB/Gyn codes for a heart procedure)? Or wrong, as in illegal?
You said: We do bill Medicare patients for non-cover services without an ABN.
Some relevant points to keep in mind. It is the doctor's responsibility, not yours, to use the ABN when necessary. The biller is not required to examine the patients chart before billing to see if it contains support for the codes submitted to you by the doctor. If you are receiving codes electronically, how can the ABN be included?
You said: What is my exposure for a client who sends us mostly level 5 visits?
What do you mean by exposure? Do you mean, can you be held legally liable for overuse of the Level 5 code? That would be a question for your health care attorney to answer specifically. But generally, do you have specific knowledge that your client is billing Level 5 for visits that are not Level 5? If your answer is yes, then I would strongly urge you to get a response from your health care attorney.
If you are interested in further information, you might Google on "Level 5 visits". That will get you to links such as these two:
http://www.medicalbillingandcoding.org/blog/leveling-up-to-level-5-visits-part-1-of-2-99205-coding-and-compliance/
http://www.physicianspractice.com/level-5-part-ii
--- End quote ---
Sorry, meant to say we do NOT bill without an ABN. We do NOT bill anything that is obviously wrong. We run a clean and ethical operation.We receive the charges on paper. We have never seen a medical record from the practice. The only knowledge of the E & M codes are they are mostly 5's. This practice treats very acute conditions so it is possible the levels are 5's.
I am consulting an attorney next week. I was looking for trade experience also. The client is under investigation by the OIG/FBI. The OIG may be thinking we were complicit.
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