Tazlar

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I am curious/concerned how much responsibility falls on the CPC of a billing office, if an audit were to occur, where the practice owner has demanded claims be sent in and someone else coded them. If a CPC knew the claims to most likely be faulty in some way but that CPC's name is not associated with them, could it legally come back on the CPC? The coder in question would not be certified. I know that ethically it would not be right to let the claims go w/o a fight, but legally/technically is there a problem that would follow the CPC indefinitely?

Thank you in advance for any advice, legally or ethically,

Tazlar
 

Skymom

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It used to be that only organizations were held liable for infractions, but it is becoming more and more common for individuals to be held responsible, as well.

First, I would request and review your organization's compliance program. It should include a method for reporting suspected violations. If your company does not have a compliance plan, I would strongly urge you to look for employment elsewhere. A compliance plan is a requirement for any individual or organization that participates in any federally-funded program (i.e. Medicare or Medicaid), and it is just good business practice to have one in any case.

False Claims Act (False Claims Act (FCA), 31 U.S.C. §§ 3729 - 3733)
The False Claim Act is a federal law that makes it a crime for any person or organization to knowingly make a false record or file a false claim regarding any federal health care program, which includes any plan or program that provides health benefits, whether directly, through insurance or otherwise, which is funded directly, in whole or in part, by the United States Government or any state healthcare system. Knowingly includes having actual knowledge that a claim is false or acting with “reckless disregard” as to whether a claim is false.

In addition to the federal law, some states have adopted similar laws designed to prevent fraud, kickbacks and conspiracies in connection with the Medicaid program.

Examples of false claims include billing for services not provided, billing for the same service more than once or making false statements to obtain payment for services.

Penalties Under the False Claims Act
Violations under the federal False Claims Act can result in significant fines and penalties. Financial penalties to the person or organization includes recovery of three times the amount of the false claim(s), plus an additional penalty of $5,500.00 to $11,000.00 per claim.

The statute provides that one who is liable must pay a civil penalty of between $5,000 and $10,000 for each false claim (those amounts are adjusted from time to time; the current amounts are $5,500 to $11,000) and treble the amount of the government’s damages. Where a person who has violated the FCA reports the violation to the government under certain conditions, the FCA provides that the person shall be liable for not less than double damages.

The Knowledge Requirement
A person does not violate the False Claims Act by submitting a false claim to the government; to violate the FCA a person must have submitted, or caused the submission of, the false claim (or made a false statement or record) with knowledge of the falsity. In § 3729(b)(1), knowledge of false information is defined as being (1) actual knowledge, (2) deliberate ignorance of the truth or falsity of the information, or (3) reckless disregard of the truth or falsity of the information.

Jennifer Ziegler, CMRS
Velocity Medical Billing LLC
 

thomas7331

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If a CPC knew the claims to most likely be faulty in some way but that CPC's name is not associated with them, could it legally come back on the CPC? ... legally/technically is there a problem that would follow the CPC indefinitely?

I understand you may be reluctant or unable to give too many specifics here in what could be a sensitive situation, but this is a vague statement so it's hard to give much advice without knowing more. I would agree with the last post in that discussing this in confidence with a compliance officer and legal specialist would be ideal - to give you a proper answer, someone needs to be able to understand the details of what has happened, who knew what and when, what were their responsibilities, how much was at stake, etc.

If that's not an option that's available to you, I guess I would just suggest that you step back and look at things in perspective. You've only said that these claims are 'most likely to be faulty in some way', and there is a broad spectrum of things that this could be, going from minor errors that may have minimal impact on payment on the one end, to intentional misrepresentation of services involving substantial sums of money on the other. Whether or not your situation would create problems that could follow the CPC 'indefinitely' would really depend on where things fall in this spectrum. A 'faulty' claim is not a crime, and audit findings of incorrectly coded claims do not necessarily lead to a fraud investigation unless the audit turns up a pattern of systematic and intentional abuse. Most payers, in most situations, will take corrective action on their own by recovering the overpayments and by alerting the provider to the problem and educating them as a preventive measure, and then secondly by increasing the frequency of the audits to ensure those errors do not continue. Turning a provider over to the authorities for investigation and/or prosecution is a last resort reserved for serious offenders. I don't want to this to sound like I'm making light of the ethics of poor coding or billing practices, but the reality is that the answer to your question will depend a great deal on the nature of the wrongdoing and the financial impact, if any, that has occurred in the situation you are describing.
 
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Tazlar

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Thank you for the replies, you input is appreciated and helpful in my further consideration/decision in how this will end.
 
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