Question Quick poll - Will I go to jail for doing what my bosses are telling me to do??

tamale79

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Our Billing and Practice managers want us to charge the assist on ALL surgeries, even if an assistant isn't allowed. I told the billing manager that I think we're going to get flagged for an audit if we charge an assist on procedures that we know don't allow it. I explained that knowingly charging something incorrectly is fraud....I never got a response.

They want to "capture" all the surgeries that our PAs assist on. (Won't the schedule do that, you ask?? Apparently not.)

Any and all opinions/suggestions/warnings are appreciated.

Thank you!

UPDATE: It looks like we're going to bill them out at zero fee. Thanks to everyone for your input!!
 
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Orthocoderpgu

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That's the kind of decision that non-coders make. However, by doing this you are opening yourself to litigation. Everyone makes mistakes and may bill a code occasionally that should not be billed. You will never get in legal trouble for that. What can/does get you into legal trouble are "patterns" of billing behavior. When you repeatedly bill out codes that you "know" should not be billed (in this case since an assistant is not allowed) that could be looked at as attempted fraud especially if the pattern repeats itself. I cannot tell you how bad of an idea this is. Incorrect payments could also be made. Are they willing to send back the over-payment in the allotted time specified? Yes, there is a specified time limit that you have to send back an overpayment. Are you willing to risk those fines and penalties as well? Bad idea!
 

csperoni

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Absolutely a bad idea for a host of reasons, as orthocoderpgu pointed out.
If this is to help track the work performed by PAs, there are better ways to do that. If it's easiest to simply run reports from your billing system to track rather than the schedule, I would propose to enter the coding with ZERO fee and not billed to insurance for codes that do not allow an assist.
That way, you can still run a report which would show:
PA 1 assisted on 18 cases in April, 15 cases in May
PA 2 assisted on 12 cases in April, 10 cases is May
etc.
I don't think you personally would wind up in jail, but it could definitely be considered fraud to intentionally bill for services that should not be billed, which could certainly result in fines and penalties.
I hope the person who suggested this did it without realizing the implications. If that's the case, help that person figure out a better way to get the data they need without even questioning fraud.
 

thomas7331

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Our Billing and Practice managers want us to charge the assist on ALL surgeries, even if an assistant isn't allowed. I told the billing manager that I think we're going to get flagged for an audit if we charge an assist on procedures that we know don't allow it. I explained that knowingly charging something incorrectly is fraud....I never got a response.

They want to "capture" all the surgeries that our PAs assist on. (Won't the schedule do that, you ask?? Apparently not.)

Any and all opinions/suggestions/warnings are appreciated.

Thank you!
It is a questionable practice to do this, but it's highly unlikely that this will be problematic, and if you are not gaining financially from whatever they are doing then you don't need to worry about going to jail. Incarceration is really reserved for the most serious crimes - I've never actually even heard of a case of coder going to jail.

Whether or not an assist is allowed at a procedure is a payer reimbursement policy - insurance companies only want to pay for what is genuinely necessary. Some physicians may request an assistant at procedures that normally don't require one for a variety of reasons, which may be for the provider's convenience but may also be because there is a complexity involved for a particular patient and they need the extra qualified hands there to help out. There's no coding rule that says you cannot code or bill for these. The charges will almost always deny because the payers have it programmed into their system to not allow an assist on certain codes, so there is minimal chance that this will trigger an overpayment. If there is no overpayment, it's highly unlikely you'll be audited because the payer has nothing to gain from doing so.

As long as the services are documented in the record, then you are not doing anything fraudulent. The worst that could happen is that the payers will target your providers for billing medically unnecessary services, and the providers will need to explain why these services were necessary. A coder would not be involved in this kind of dispute, as it's a clinical kind of review that would be conducted peer-ot-peer.
 

Bluteam

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Does anyone know what the billing guide lines are for billing a profession claim withy mod 26 reading of the radiology reports if the facility bills with REV code 450 and OBS with REV 762 are we doing incorrect billing by changing the Place of service from 22 outpatient to 23 emergency room when the patient is taken from OBS to another area the hospital registers the patient as 22 place of service the Revenue has to be made by reregistration of each dept patient is going to for MRI CT ect.... our billing auditor states this is incorrect billing and fraud ............. CMS states if there is a contradiction between facility vs professional that you follow the facility so by changing the POS we are matching what the facility is billing how can this be WRONG
 
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