fraud in billing?

JSHAFER

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I am reviewing a bill for a patient from another physician office and have found it to be absolutely against AMA coding guidelines. As well, there was a medical device given to provider as a sample but he charged patient for device. So my question is this....

Who do I report this issue to?

There is no insurance carrier involved as patient is self pay so I cannot advise them to report to insurance for chart audit and payment retraction. If this is the kind of billing he does for a self pay patient then I can only imagine the gouging he is doing to the insurance company. Definitely has my blood boiling!!!!
 

thomas7331

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If the patient is self pay, there isn't much you can do - there's no violation of the false claims act if there was never a claim billed, and for self pay patients there's no particular law that says charges have to be supported by documentation, at least that I'm aware of. If you think the patients are being unjustly overcharged, you could perhaps think about going to a consumer protection agency, but the reality of it is that it would be up to the patients to decide whether or not they received value for their money since they're the ones who actually received the services.
 

ahguzman

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Has the patient attempted to resolve this with the physician's office himself? Is the office private or hospital-owned? Not that I'm advocating for the office but remember fraud requires intent and knowledge. Mistakes happen- especially with EMR and "charge entry" and the provider is merely trying to document a service was provided (the device) and a charge is populated erroneously. Granted the charges (with $ amount) should have been reviewed before submitting to the patient or an insurance company to capture such errors, however this doesn't automatically constitute fraud. I would definitely suggest the patient contact the office if he/she hasn't done so already. A hospital-owned office will have more avenues to persue for reconcilation than a private office.
 

Pam Brooks

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Although it sounds like you are helping out someone who has a question with their bill....remember your code of ethics. Assume positive intent here. You don't know for sure if there's been any "gouging" or improper behavior, and to go into this loaded for bear without first getting all the facts is a misuse of your coding certification. You certainly don't want to come across as an 'expert' only to learn that you have it all wrong. Because this is a self-pay case you really don't have any recourse with any carriers. As far as being against AMA guidelines, I'd caution you that unless there is clear intent to defraud the patient (vs. a mistake), you don't really have anything to go on, other than perhaps sloppy bookkeeping on the part of the physician. Was the device given to the practice, or provided at a cost? Make sure first. Sometimes patients hear what they want to hear, and you don't want to get sucked into any drama without knowing exactly what happened. And make sure you have written permission from the patient to become involved with their bills. Although payment doesn't fall under HIPAA, your AAPC code of ethics requires that we act with integrity, respect, commitment, competence, fairness and responsibility.
 

CodingKing

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Fraud is a very bad word unless there is proof of intent to defraud its not fraud.

Is there an AMA guideline about not billing for "samples"? My understanding is that is more of a contractual issue between the physician, patient, and payer. If you don't have insurance I don't believe any of that applies.
 

sab001

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although it sounds like you are helping out someone who has a question with their bill....remember your code of ethics. Assume positive intent here. You don't know for sure if there's been any "gouging" or improper behavior, and to go into this loaded for bear without first getting all the facts is a misuse of your coding certification. You certainly don't want to come across as an 'expert' only to learn that you have it all wrong. Because this is a self-pay case you really don't have any recourse with any carriers. As far as being against ama guidelines, i'd caution you that unless there is clear intent to defraud the patient (vs. A mistake), you don't really have anything to go on, other than perhaps sloppy bookkeeping on the part of the physician. Was the device given to the practice, or provided at a cost? Make sure first. Sometimes patients hear what they want to hear, and you don't want to get sucked into any drama without knowing exactly what happened. And make sure you have written permission from the patient to become involved with their bills. Although payment doesn't fall under hipaa, your aapc code of ethics requires that we act with integrity, respect, commitment, competence, fairness and responsibility.
nicely stated!
 

JSHAFER

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Thank you for input. Rest assured, I take my certification very serious and have not gone any deeper than posing the question here for advice.
 
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