Is this fraud?

nestes22

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Could this be fraud?

I have a concern that I've been looking into for a little over two months now with a company I am in business with. The problem I've seen is that their claims are getting denied by medicare due to the referring providers not being enrolled or not being eligible to order or refer for medicare patients. However, once the claim is denied there is a regular practice of assigning the NPI of a different provider that is enrolled with medicare on that same claim and resubmitting it as a claim correction so it will get paid.

I've found a number of articles that talk about this and I know that reporting for services that you didn't actually provide is definitely fraud. I don't know if this is the same thing though, I've also only been certified for a short time so I'm not an expert by any means. I'm just a little worried that this is a bigger compliance issue than what the organization understands and could potentially put me and my licenses at risk if I continue my involvement with this company. I've brought up my concerns with the organization and helped create an action plan to change these practices but I'm still seeing it blatantly being done regardless of the steps taken to stop it.

I feel obligated to report this but when I contact CMS or HHS directly to ask questions they are helpful but both have told me they can't say what is fraud or what isn't they just take the reports, so I'm looking for advice and opinions on what others have encountered, how they handled it, and what you think I should do in this situation.

Any advice with this is greatly appreciated.
 
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They can't change the name and NPI of the referring provider to someone who did not do the referral in order to get payment. This is a textbook case of fraud.
- Falsifying documentation
- Altering claim forms to receive a higher payment amount

If you've escalated it within your office/facility and nothing has changed, I would definitely recommend bumping up your concerns to the state or federal level. Here's a link to help you:
https://www.cms.gov/medicare-medica...nsumers/report_fraud_and_suspected_fraud.html
 

sab001

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It is considered fraud if the provider is doing it with intent to deceive the payer for the purpose of obtaining reimbursement. It is considered abuse if there is no intent to defraud the payer but the outcome from the billing mistake results in reimbursement. Regardless of if it is fraud or abuse, the provider has a duty to self-report and refund any over-payments made to them back to the Medicaid program, Medicare contractor, or payer (if contractually obligated to do so.)

Follow the instructions given to you by the previous respondent, PMdanskangel313. First report it to either your compliance officer or through the company you are doing business with. If you are not employed by the business, there is likely a business associate agreement in place that will spell out how to report as well.

You can report anonymously to the OIG 1-800-HHS-TIPS (1-800-447-8477).

Scott B.
 

CodingKing

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How about if the claim goes out with a provider such as a Chiropractor who does not have an NPI? What should be done in this case?

The chiropractor should apply for an NPI. They wont be able to bill until one is assigned. No one else can bill for the chiros service under their NPI becasue chiro doesnt qualify under incident to guidelines.
 

areese

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Example

Could you give an example of what you are dealing with. I could see this as compliant or non compliant depending on the situation. Example: Was it a NP that bills under a doctor that referred patients to you guys? Example: Did someone refer a patient to you for an office visit and then you decided to do testing on the patient that day that the referring would not be authorized to order, yet all services are billed on one claim?
 
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We have chiropractors that refer to our office (pain management). We perform injections and Medicare requires a referring/ordering provider on X-rays and Labs. These are the claims that are denied for the referring provider not able to order/refer. We were changing the ref md to the primary and this gets it paid. But now after seeing this thread I want to avoid fraud.
 

areese

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Your doctor is the ordering

It sounds like to me that your doctor ordered the injections, labs, and x ray after someone referred them to your office whether it is a chiropractor or their grandma. Your doctor would be the ordering correct?
 

npricercm

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is ths fraud?

I have a concern that I've been looking into for a little over two months now with a company I am in business with. The problem I've seen is that their claims are getting denied by medicare due to the referring providers not being enrolled or not being eligible to order or refer for medicare patients. However, once the claim is denied there is a regular practice of assigning the NPI of a different provider that is enrolled with medicare on that same claim and resubmitting it as a claim correction so it will get paid.

I've found a number of articles that talk about this and I know that reporting for services that you didn't actually provide is definitely fraud. I don't know if this is the same thing though, I've also only been certified for a short time so I'm not an expert by any means. I'm just a little worried that this is a bigger compliance issue than what the organization understands and could potentially put me and my licenses at risk if I continue my involvement with this company. I've brought up my concerns with the organization and helped create an action plan to change these practices but I'm still seeing it blatantly being done regardless of the steps taken to stop it.

I feel obligated to report this but when I contact CMS or HHS directly to ask questions they are helpful but both have told me they can't say what is fraud or what isn't they just take the reports, so I'm looking for advice and opinions on what others have encountered, how they handled it, and what you think I should do in this situation.

Any advice with this is greatly appreciated.

I would find an attorney. There are a number of them that specialize in this area. It is a legal term. why are they changing just to get paid? Did someone direct that be done for some reason? Do you have proof of any kind? Does the company have a relationship with an attorney? Having a plan that is being ignored, is everyone aware of the plan down to the person who fixes the claim and sends it out? How far does this practice extend? Does everyone know? An attorney can help you sort through all the ins and outs so you can make an informed decision.
 
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Chiropractor

I would be concerned if a chiropractor does not have an NPI. That would mean they can't bill or credential with any ins. It's odd one wouldn't have one. It's up to your office to know if a referring provider is out of network. If they are then you can have patient sign an advance beneficiary notice (ABN), which shifts the responsibility to the patient to pay for service not covered due to out of network provider and you can bill the patient. I guarantee once a patient knows a service will deny and cost them, they will find a chiro in network to refer them. I am supprised a Medicare patient is seeing a chiropractor out of network. The patient is paying out of pocket or the chiro is billing fraudulent as well.
 
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