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Thread: Legal Question

  1. #11
    Join Date
    Apr 2007
    Charlotte, NC


    AAPC: Back to School
    Actually, downcoding, while not as sever an issue as upcoding, is still wrong, legally and ethically, and the doctor can be fined for it. You can, I believe*, always offer a patient a self-pay option if they say upfront that they have financial hardship or you can always set up the hardship program that deeva mentioned.

    If however, the patient decides to go with ins or self-pay, they can not look back for that visit.

    But your practice and doctor should not downcode even once.

    * while I may believe, I am also wrong alot.

  2. #12


    This is definitely illegal. 9921X is for a problem oriented medical visit and requires a diagnosis (chief complaint) and it is clearly spelled out in the guidelines. If the patient is coming for the annual, to obtain payment, your employer is likely using an unreported chief complaint. This is a textbook definition of a false claim. They can charge reduced fees if they want to help but to compromise his/her license is crazy and not recommended.

    There may be situations where the patient has a history that warrants a Pap (abnormal results/PAP). I would recommend using those dx code with the PAP.

    Good luck, I encountered this situation before and left the practice because, unlike a physician, I will likely be unable to afford a high priced attorney to keep me out of jail. (Yes, they prosecute coders for fraud too).

  3. #13


    Go to the back of the CMS1500 form and read the attestation that the provider is signing their name to EVERY time they file a claim.
    "Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading information may be guilty of a CRIMINAL (emphasis added by me) act punishable under law and may be subject to civil penalties. Under penalty of perjury, I declare that I have read the foregoing; that the facts alleged are true, to the best of my knowledge and belief; and that the treatment and services rendered were reasonable and necessary with repect to the bodily injury sustained."

    That's a pretty darn strong statement they are signing their names to.

    I also refer you to (as mentioned by several other posters) the False Claims Act. They address several problems, but pertinent to your situation: Services not rendered.

    Then, say your provider gets red flagged, PER claim, they can be penalized at a minimum of $5,500 up to a maximum of $11,000. Plus, the provider could be liable for up to three times the amount unlawfully claimed.

    Not to mention the added Civil Monetary Penalities and potentially being excluded from Medicare.

    Doesn't sound like something anyone wants to get into.

    Everyone wants to help the patient, I understand that. That's what we are in this business for. However, just because the "patient doesn't have wellness coverage and their deductible is very high so only charge 99212"

    You are falsifying your claim to seek reimbursement from the government, that should really be from the patient. The patient needs to understand their plan and policy -- healthcare is an expense to them too for some services.

    Hope that helps.
    Last edited by ARCPC9491; 08-17-2009 at 09:45 AM.

  4. #14
    Join Date
    Apr 2007


    Quote Originally Posted by klp010102 View Post
    Ok after reading that it doesnt seem to be a problem with them discounting private pay patients?
    Yes they can give a discount to private pay patients. We give a percentage to our private pay patients also.

  5. #15


    Quote Originally Posted by cpccoder2008 View Post
    Yes they can give a discount to private pay patients. We give a percentage to our private pay patients also.
    My understanding is that the discounting has to be detailed in your policy and procedures to provide evidence that the process is fair and applied universally under the criteria set for eligibility. This helps your practice to avoid *even the appearance* of playing favorites, while allowing you to provide excellent consideration for patients with increased need.

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