Pediatric Coding Alert

Physician faces up to ten years in prison for the crime.

If you think Medicaid claims aren’t being scrutinized the same way Medicare claims are, think again.

A New Jersey pediatrician was arrested at his home on Jan. 16 and charged with fraudulently billing Medicaid $900,000 for wound repair treatments on children that the government alleges he never performed. Not only did the physician’s documentation not support the wound care cases (which involved suturing or stapling facial wounds larger than 30 cm), but when the government asked the children about the services, they noted that they had never experienced facial wounds.

The pediatrician faces up to ten years in prison or a maximum fine of $250,000 for the grossly fraudulent charges.

Stay out of the crosshairs: The Department of Justice went after this pediatrician, but it’s unclear how the DOJ was tipped off about the pediatrician’s wrongdoings. In most states, Recovery Audit Contractors (RACs) have begun auditing physicians’ Medicaid claims, and you don’t want to be discovered to be billing and coding inappropriately if a RAC auditor visits your practice. Ensure that your documentation is pristine, and perform self-audits if necessary to confirm that you are documenting appropriately.

In addition, some states allow you to read their current Medicaid audit issues by visiting your state Medicaid Web site. For instance, Indiana Medicaid notes that it is performing credit balance audits, while Missouri is reviewing behavioral health services and documentation. Check with your state Medicaid representative to find out the open issues being reviewed near you.

To read the complete news brief on the New Jersey pediatrician’s case, visit www.justice.gov/usao/nj/Press/files/Badawy, Badawy Arrest News Release.html.