Question Am I being asked to commit fraud?

zathras1974

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I have a question for those who have been doing this longer than I have.
First, let me set the scene.

I'm a recently credentialed CPC (Early March 2021) who is working at a third party biller who ships and bills for Remote Patient Management devices. BP Cuffs, Scales, Glucometers, and (soon) Pulse Oximeters.

This is a somewhat new company. Myself and two others were hired around the same time to set up the billing department.

Everything was fine until last Thursday. The other two billers were out of the office (one sick, one had an appointment). One of my managers comes to me and asks about a discrepancy between what a client asked us to bill, and what we actually billed. It looks like the system was marking things that we had rejected as unbillable as billed. I investigated and alerted them of the issue, and that it wasn't anything to worry about, just a quirk between what the client wanted us to bill, and what we legally COULD bill.

Example 1: Code 99457 is for time spent discussing results with patients. Must be 20 minutes or more within a 30-day period. If the provider doesn't meet the time requirement, we don't bill it. Client wants us to bill it, but we kick it out as unbillable.
Example 2: Code 99454 is for monthly "maintenance". Normally must have 16 readings in a month. Due to the pandemic, CMS has lowered requirement to 2 readings a month. Some patients are non-compliant and don't even meet this lowered bar. Client wants us to bill it, we kick it back.

So the system is showing we billed it, but our claims revenue is about 40% lower then what management expected, due to us kicking out unbillable requests.

Now to the sticky part. Management wants us to go back and bill these 99454's, even if there are no readings. Their justification is that "Since the system sends an alert to the patient that they missed a reading, that counts as a reading".

When I pushed back on this idea, saying that a lack of a reading couldn't BE a reading, the manager asked if we had to provide documentation along with the claim, or if the only way CMS would find out is if we were audited.

Obviously this makes me, and the other two billers, very uncomfortable. We haven't billed this questionable way, and we were supposed to have a meeting with management on Friday about the issue. That meeting never occurred.

I'm one week away from my 90 day's, and don't want to cause a stir, but I also (obviously) don't want to be fined or jailed for committing Medicare fraud.

So, IS it fraud, or am I getting myself worked up for nothing? Any advice would be appreciated. I can't find any documentation that states this is fraud, but it SURE feels like it.

Thanks in advance.
 
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Hi there, I don't blame you for feeling uncomfortable. It's not possible to say this is certainly fraud, that requires a conviction or guilty plea following an investigation and so on. It doesn't look like compliant coding/billing that would stand up on review but it may be that the manager doesn't understand the rules and just wants to please the clients. Explaining how much trouble this could cause the client - including the need to return a lot of money - might be all it takes.

So far as you and the other billers are concerned the only time I've heard of billers/coders face legal consequences for fraud is if they're directly involved in coming up with the scheme, directly benefit from it or help conceal it (eg falsify or destroy records). If this ever comes down to an investigation the folks who were "just following orders" can expect to be interviewed by the investigators and they will want to have their own attorney with them for those interviews. They may also have to testify in court if it goes to trial. Sorry I don't have a solid yes or no answer.
 

Pam Brooks

True Blue
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I think that this is most definitely an issue. If the service didn't happen (for whatever reason), you cannot bill for it. If a time based code doesn't have chart documentation that shows the time, you can't bill it. Perhaps you should provide management with the Medicare Program Integrity Manual. The False Claims Act is another document you should share with them as it outlines monetary penalties related to fraudulent billing. Above, all, document everything that's happened with regards to this issue: what, when and who asked you bill these, and make sure you have a copy of this at your home. It may be that they're not aware of the implications of submitting a claim that is false. Let's assume positive intent, and that they're simply trying to catch up from a revenue perspective and aren't aware that what they are asking you to do is wrong. But it most definitely is wrong.

They hired you to do the correct and compliant coding and billing, so if after you explain compliance to your managers, they continue to ask you to bill in a way that is non-compliant, you certainly do have choices. I'll leave that up to you.
 

SharonCollachi

True Blue
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Whenever someone says, "how would they find out?"... you know you're doing something wrong.

I have a saying, "It only takes ONE pissed off patient..." Your patients get EOBs and it only takes ONE of them to report that they did not receive something (an item or a service) to start the audit-ball rolling.
 
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