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Wiki Fraudulently billing

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tbragg36

Networker
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Location
Bonita Springs, FL
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How do I protect myself if I think my provider is billing fraudulently? I have researched our codes and informed my supervisor on several occasions that we shouldn't be using these codes. My supervisor says they have researched these codes and the codes being used don't even represent 50% of the work being done. I don't want to keep submitting these codes to the carriers. Until I find a new position, what can I do?
 
Put it in writing. Be specific about what you feel is incorrect and email it to the provider and supervisor. I had a similar situation and I refused to send those claims...someone else in the practice did it.
 
You can go to your internal compliance department if you feel something is not correct and your direct supervisor/manager is not addressing your concerns. You should (hopefully) have a way to do this anonymously if you are not comfortable.
 
Thanks for the help. My provider is a very small practice and there are only a handful of people. We bill 4 codes and I have sent her all kinds of documentation of billing restrictions of these codes and how they should be used. I get verbal directions on what to submit and getting things in writing is sometimes hard. I recently showed her Medicare's publication stating that this code would NOT be likely medically necessary more than 3 times a year. We bill it every week.
 
tbragg36 said:
Thanks for the help. My provider is a very small practice and there are only a handful of people. We bill 4 codes and I have sent her all kinds of documentation of billing restrictions of these codes and how they should be used. I get verbal directions on what to submit and getting things in writing is sometimes hard. I recently showed her Medicare's publication stating that this code would NOT be likely medically necessary more than 3 times a year. We bill it every week.
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Getting something in writing is always the best in a situation like this, but if you can’t do that, you can at least keep you own notes documenting in detail the conversations you’ve had with your providers and/or management. Email them to yourself so that you have a record of the dates.

Honestly, though, it’s highly unlikely that you’d be accused of participating in fraud in your position since if you’re just being paid hourly you don’t even stand to benefit financially from anything your provider is billing. So you should take steps to protect yourself just as a precaution but I wouldn’t lose too much sleep over it, just based on what you’ve said here. Though you haven’t shared the details of what your provider is billing, from the sound of it, it doesn’t really seem like fraud. Fraud is intentional misrepresentation and usually consists, for example, of billing for services that were never even performed. An honest difference of opinion between a provider and coder, or between a provider and payer about what is medically necessary or about how to interpret coding guidelines is not going to rise to the level of being considered fraud. And if a provider is billing a service more frequently than a payer truly considers necessary, the payer is free to deny it, and usually will. It’s only if that service wasn’t actually performed that you start to get into the area of fraud.
 
Thank you, Tom. I will provide you with more insight. Our codes are as follows: 95957, 99483, 95816. We are billing for what the provider calls brain therapy. We are billing the 95816 like a physical therapy code 3 x a week for some patients. From what I have read 95816 (EEG) is a diagnostic code and has DX restrictions for the state of CA (I find it odd that Noridian keeps paying the 95816). The DX codes we use for the 95816 are not on the list of LCDs. We are using CPT 99483 as a review of treatment. The 99483 code is a timed code of 50 minutes and has 10 bullet points that must be met. Our documentation says 30 mins spent with patients and no bullet points have been met. The code 95957 is a special EEG and should not be bill more than 3 times a year. We are using the 95957 for interrupting the 95816 EEG report, and we bill 95957 every Sunday. All of our DX codes are for anxiety, depression, insomnia, dyslexia, and so on. I'm trying to avoid getting caught up in this mess until I can find different employment.
 
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Is it fraud? Probably not. But if your providers are being made aware to a coding issue AND educated about it, and still continue to bill incorrectly, that's NOT ok. That's abuse and puts the office at risk. If audited by CMS, it could result in a notice of non-compliance, ICAR, CAR or a CAP.

Good for you for protecting yourself and doing what's right.
 
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