Wiki Liability of billing companies

[LLovett]

I know that when we deal with outside vendors for coding, our contracts state that we (the client) are still responsible for making sure the claims are correct.

So here is the scenario I am not so clear on.

If you use a billing company, they provide the software, your staff enters in the information, then they are responsible for filing the claims and doing the follow-up.

They get paid a percentage based on what they collect for you. What happens if they change the information you entered in their system, in order to get paid, thereby creating fraudulent claims?

Is the provider still responsible or is the billing company held liable?

I keep up with the OIG goings on as much as possible and I can't recall ever seeing this type of situation addressed.

I like to know all the ins and outs before I get involved with other companies.

Thanks for any input,

Laura, CPC, CEMC

 

[cyndeew]

Liability of Billing Companies

Laura:

A billing company should NEVER EVER change a code in order to get paid. They are supposed to be transferring the information provided by the healthcare provider into a format (claim) to submit to a carrier. If a change happens, it should be thoroughly documented on paper or in the patient's file within the billing program and it should have permission given from the provider or provider's staff. Otherwise, there shouldn't be a change.

Obviously, some things a biller can correct possibly, but again, there should be a notation. Changing a code though - Unh Unh. This is a huge risk for the biller and for the provider if the biller makes a change like that.

If it's an issue where denials are happening frequently, the biller should be getting with the provider's office to understand why they are happening and to find out if there is anything they can do to prevent the denials or if it is a case where it just flat isn't covered.

Even where the provider enters their own patient demographics and charges into the biller's system, changes should NOT be made without proper documentation on the reason(s) why.

As for percentage of collections - well that's a whole other subject and depending on the state you're in, it might be illegal.

 

[bettze1947]

Billing Companies

I understand the predicament. The providers turn in charge tickets, some put their own codes on it and others just write in the diagnoses and procedures-they usually provide E&M codes. If we see something that is coded by the provider incorrrectly, like a diagnosis for diabetes and one for kidney failure as separate codes instead of a combined code, or an E&M codes that are consistantly level 4 & 5's, our staff has been told that because we are a billing company, we have to enter and file claims as the encounter forms/charge tickets indicate. We ar discouraged from querry providers becaus they are upset when we send the charge tickets back.I feel that if we are CPC/CCP, etc, that if we know that is is incorrect, we should querry the provider and not send out a claim that is incorrect. Also, we have some providers that will bill a diagnostic procedure with a moreinvolved one in which the diagnostic is included in the complex one and a contr-lateral procedure with left and right and -59 and -51 modifier when as a CPC I recognize this as unbundling.
We have been instructed that if we are ever audited, that it will be the providers that take the hit, but I think the OIG Compliance Plan for Billing Companies states that we will be held responsible for knowingly filing fraudulent claims. Our Director says our services contract protects us and I think that a contract will not shield againt a Federal OIG mandate.
This is the first time I've worked for a Group that has had this kind of attitude and I am increasingly uncomfortable with these coding and billing practices.
Billing Companies are not teflon-coated and if there is ever one audited that has similar practices, I would like to know what impact the audit had on the coders and account representatives.

 

[cyndeew]

Billing Companies

BJ - I concur with your thinking. If you know something is being submitted that is unbundling and it is submitted anyhow, absolutely, the biller can be held liable too, especially for Govt. claims - that constitutes a false claim and knowingly doing so now will get you even quicker with FCA's new teeth. (see the newsletter from AMBA General Compliance Counsel)

The OIG guidelines for billers specifically addresses upcoding, unbundling, inadequate resolution of overpayments, and etc. as being problematic. The guidelines are intended to improve communications between billers and providers and to give staff members a clear understanding of how to handle these types of situations. And, the billing company is supposed to conduct random and routine audits to detect this kind of thing.

There is no free pass for a billing company or their biller. These types of practices are specifically and exactly what the OIG is trying to prevent and detect.

 

[LLovett]

Thanks!

Thank you for the responses! I greatly appreciate it.

It is always good to be well informed!

Laura, CPC, CEMC

 

[mitchellde]

Laura, I came in this one late, but the billing company I provided consulting for would never believe me when I tried to tell them they could not change codes unless they were guided byt he documentation and with communication back to the physician. Her response was always that they were paid to get the claim paid so whatever that took. This is why I felt I could no long work there, then recently I hear she attended a meeting and found out that she is responsible and those that still work there say she came back in a tizzy, she fired a ton of people and tried to make it appear that the coders and billers were at fault when they were following orders to keep their jobs. I know her day is comming!