Keep a Paper Trail: Let Documentation Protect You when the OIG is at Your Door

By Jo-Anne M. Sheehan, CPC

I work hard informing my staff and clients of the constant changes to health care coding and billing regulations. To keep up with the Office of Inspector General’s (OIG) compliance plan, my employees maintain an on-going log of communication between our clients, insurance carriers, and themselves.

Record keeping helps us pinpoint weak areas in both offices and allows us to find practice management solutions. For many, keeping proof of facsimile transmissions, email, traditional mail, and telephone conversations may seem paranoid. I see it as protection for employees and clients, should they wrongfully be accused of suspicious behavior. Incident and corrective action reports are kept in a client’s file to ensure communication delivery and follow through.

If reported incidents are ignored by a client after numerous citations, we give final warning and ultimately terminate our relationship for non-compliance. This may sound harsh, but we do everything we can to help our clients and trust they want to follow the rules as much as we do. Some physicians are too busy and others trust their office manager to handle their problems; either way, negligence places both offices in a precarious position.

Although I am apprehensive when it comes to liability issues, I do my best to help anyone before we part ways. Sometimes, when you try to do right and help clients, trouble can still arise. For 28 years, my employees and I had not come in contact with a dishonest health care professional. Some were questionable, but we never uncovered proof of unlawful activity.

Knock, Knock, Knock

I thought we had our clients’ practices under control until two government security agents representing Health and Human Services (HHS) and OIG barged into my office holding up badges and asked if I was Jo-Anne Sheehan, owner of Lomar Associates.

I felt my knees weaken as I answered and my mind went through a checklist of things that might have gone wrong.

  • Did I owe the IRS money and fail to send them a check?
  • Was someone in my office suspicious of illegal behavior?
  • Did I not shred patient information properly?

I was at a loss. I am the person who will not walk across a lawn if the sign reads “Do Not Walk on the Grass.” What could I have done to warrant such a frightening encounter? These agents were professional and behaved sternly. I immediately recognized the seriousness of their visit.

The female agent rambled off my Social Security number, home address, and other personal information, asking for verification. I answered her questions and wondered how she knew so much about me.

“Do you provide billing services for a Janice Smith (name changed), owner of Physical Therapy, Inc. (name changed)?”

I responded with “Yes” and added that I terminated my business relationship with her for non-compliance of corrective action citations. We were, however, continuing to bill services for her as a courtesy while she looked for a new company to take over, I explained.

“We are here because we believe that Janice Smith is in serious trouble with Medicare. She is currently under criminal investigation,” the male agent said.

My heart sank; I thought this may happen one day. I wondered if Janice and her office manager were naive or intentionally ignoring the problems cited within the practice. My staff questioned her ethics but I wanted to believe Janice was a nice woman who didn’t understand the seriousness of her billing and coding practices. I was wrong.

The final question the female agent asked said it all to me. “Did you write an anonymous letter to Medicare stating that Janice Smith was guilty of Medicare fraud?”

My Answer Was “No!”

A series of visits took place involving intense staff questioning from agents. Phone calls flowed between the government, my office, and my attorney. Medical records were confiscated. No conversation took place between Janice and my staff during the initial investigation.

I’ll never recover the time lost assisting the agents, but what I learned was invaluable—the government believes you are innocent until proven guilty and wants to work with providers to help them understand correct service documentation.

Some audits reveal inaccuracy and cost practices’ money, particularly if services were overcharged based on a provider’s documentation, but this is classified as abuse and not deliberate.

All it takes is one anonymous letter to Medicare citing reasons why a medical provider might be guilty of fraud and abuse and investigations begin. It is commonplace to monitor practices for unbundling/bundling and over/under charging, and to have medical records requested for review of questionable practices; however, when someone blows the whistle on a health care professional citing evidence, the investigation is of a different nature.

No Stone is Left Unturned

Now, I understand why the OIG promotes paper trails of communication through incident and corrective action reports. This proof of dialogue helps clients and third parties during a criminal investigation. I shudder to think of what my business may have endured or been accused of if I had not followed this component of the OIG’s compliance plan. The documented warnings I sent to Physical Therapy, Inc. were available for the agents.

If a provider is tried before a grand jury and sent to jail for fraud, they are convicted felons. The government doesn’t have time to bring every abuser to trial, so if a physician or ancillary provider reaches this level of the investigation, they are in serious trouble. My former client, a new mom, is serving ten months in federal prison for fraud and will be on two years probation after her jail term. I do not believe she is an evil person; however, greed got the better of her and she didn’t think she would get caught.

Learn, Maintain, and Teach Coding Excellence

Most providers run their practices ethically while maximizing reimbursement to compensate for continuing reductions. It is our expertise as certified coders to capture all billable services for providers. We serve our clients and teach them coding techniques that are appropriate to help steer clear of compliance interrogations.

As long as the medical profession requires legal documentation to back up their services, certified coders are in demand. Coding is a profession we have worked hard to attain, and our love of coding which prompts us to maintain CEUs, test our coding knowledge, attend chapter meetings and seminars, and spread the word about the importance of coding excellence.

To report fraud you can call the OIG Hotline at 800-HHS-TIPS.

Fax:        800-223-8164

E-mail:   HHSTips@oig.hhs.gov

TTY:      800-377-4950

Mail:      Office of the Inspector General

Dept of Health & Human Services

Attn: Hotline

PO Box 23489

Washington, DC 20026

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