Wiki UPIC

[davehudgb]

I fully understand and acknowledge that any response or feedback is not legal advice in any form.

I work for a medical billing agency. One of our providers were notified that they are now in a UPIC audit for Wound Surgical Supplies. We assist the provider with gathering the documents required for the claim. We then assist with feedback about the medical documentation indicating what is lacking in respect to the document not meeting the minimum requirements according Medicare's LCD or Articles of Coverage.

Here is what is being asked by the owner's of the company and the owner of the agency I work for: They are asking that claims be filed to Medicare where the documentation is not clear or could be denied during the review process once Medicare requests all required documentation. We have been through several TPE Audits in this area of wound care supplies with other providers and we are aware of the gray areas ect. The theory for the wound care DME provider is that they feel this will indicate they are not filing fraudulent claims. I expressed to my employer that this is not a time to attempt this type of stance. I was asked to file claims that the owners of the DME Provider have initialed and signed off on to send to Medicare. It is my opinion that if the Ordering Providers medical documentation does not meet the minimum requirements according the to LCD/Article we should not be filing the claim. Isn't that fraud/misuse ect?

Can I be held accountable in filing said claims on behalf of the provider / employer? I thought if any individual knows of any misuse - fraud ect can be held liable by Medicare.

 

[jkyles]

Hi, I apologize in advance that this isn't a clear answer. Here are somethings to think about.

1. Fraud requires a criminal conviction, so there's no fraud yet.
2. If you're really concerned about what you're being asked to do, you need to speak to an attorney.
3. It is extremely rare for coders and billers to be penalized or investigated for work they do on behalf of someone else, even when the provider is convicted of fraud. Typically it takes the coder being directly involved in creating a scheme to commit fraud.
4. BUT, that doesn't mean you can assume nothing will happen to you.
5. Because if investigators get involved they may want to question you. In a fraud case they'll be after information about your employer and trying to determine if you were directly involved in creating a scheme to commit fraud.
6. You will need to have an attorney present while you're being questioned. If your employer doesn't provide an attorney, you'll need to retain one yourself.
7. At the very least you should start keeping careful notes of conversations you have around this issue.
8. Good luck.