Page 1 of 2 12 LastLast
Results 1 to 10 of 19

Need to report fraud, need some guidance

  1. Thumbs down Need to report fraud, need some guidance
    Exam Training Packages
    I'm in my first coding/billing job. Unfortunately, little alarms kept going on in my head about the way they did things but I couldn't quite put my finger on what was going on. Last Friday, I figured it out. This week, I verified that it was happening. Basically...a doctor can't be in two locations seeing patients in both at the same time. The issue seems to be being done on purpose, and it's causing payers to pay us more...which it seems those involved know and that's why they do it.

    What do I do? I need to call the fraud line for sure. How and when do I quit my job...basically, should I just call them and say "I'm sorry I can't come in any longer" and leave it at that? I don't want my name attached to anything involving this! Do you need a lawyer to report this type of thing?
    Last edited by aprilsue; 01-03-2012 at 06:04 AM.

  2. #2
    Location
    Columbia, MO
    Posts
    12,572
    Default
    Have you consulted with your employer first? Are you absolutely certain this is fraud? Are you certain they are doing this intentionally for profit? or is it possible they are following the instructions of someone previous to you and are unaware of the issues? Can you give a more clear picture of what is being done? An attorney could advise you better but you need one that is specifically adept with health care fraud and all the rules and regs.

    Debra A. Mitchell, MSPH, CPC-H

  3. Default
    I am a little confused too, can you be more specific? Are they actually creating a fake patient encounter? Is the Physician Assistant, Nurse Practitioner seeing the patient and they are billing under the physician's name?

  4. Default
    Quote Originally Posted by penguins11 View Post
    I am a little confused too, can you be more specific? Are they actually creating a fake patient encounter? Is the Physician Assistant, Nurse Practitioner seeing the patient and they are billing under the physician's name?
    billing under the doc name..pa is providing the service...doc is in another city hours away.
    Last edited by aprilsue; 01-03-2012 at 06:18 AM.

  5. #5
    Location
    Columbia, MO
    Posts
    12,572
    Default
    as you know you cannot participate nor allow this to continue, you can fix it or report it and leave. If they know it is wrong but continue to do it because the reimbursement is higher, or the PA is not credentialed it is wrong. You must bring it to their attention and set things right if you can.
    I have responded to your PM.

    Debra A. Mitchell, MSPH, CPC-H

  6. #6
    Default
    Quote Originally Posted by himgirl View Post
    I'm in my first coding/billing job. Unfortunately, little alarms kept going on in my head about the way they did things but I couldn't quite put my finger on what was going on. Last Friday, I figured it out. This week, I verified that it was happening. Basically...a doctor can't be in two locations seeing patients in both at the same time. The issue seems to be being done on purpose, and it's causing payers to pay us more...which it seems those involved know and that's why they do it.

    That's a skimmed down version of it, there is more unfortunately.

    What do I do? I need to call the fraud line for sure. How and when do I quit my job...basically, should I just call them and say "I'm sorry I can't come in any longer" and leave it at that? I don't want my name attached to anything involving this! Do you need a lawyer to report this type of thing?

    It's my first job out of college in this field...and I'm pretty upset.

    Whoa, now...as it's been mentioned, be careful before throwing around the 5-letter "F-bomb". You could be mistaken about what you're witnessing (remember, you ARE new, and although this field is heavily regulated, and some of the regulations are clear, there are a LOT of exceptions to the rules that you may not be aware of; the laws are very complex, and often require legal analysis by an attorney to interpret accurately). Or, you could be absolutely correct, and are merely witnessing an innocent mistake from lack of knowledge. I'd speak up and ask there, first, but in the most tactful, and non-accusatory manner possible - ask with a 'curious-mind', how it's possible that things are being done the way that they are. If you have knowledge of a specific rule that being broken, ask how the arrangement conforms to the law. As long as you're respectful and humble about it, you shouldn't face any backlash.

    If you do, it may be because there really is some impropriety going on - at that point, you'd have a legitimate cause for concern, so reporting to the authorities would be justifiable. IF (and only if) you are certain that it's intentional fraud (which will probably be because you are retaliated against in some manner for innocently bringing up the subject), a call to the OIG may be warranted. There are laws in place to protect whistleblowers from retaliation, and to reward the reporting of legitimate fraud to the government. Keep in mind, though, you can only report that to them, if government payers are involved. Otherwise, it's a breach of contract issue for the commercial payers to handle.

    Tread lightly - you're in uncharted territory, and it can be a dangerous place to be. You don't want to lose a good job, or potentially smear someone's good name, over a simple misunderstanding.

  7. Default
    I agree with the bringing it too someones attention, but you also have to keep in mind the insurance carrier involved. If they are doing this for all of the carriers this is definitely incorrect but some carriers have different rules. For some of our commercial carriers they do not want anything billed under the PA's name, they want all services billed under the physicians name including office visits and surgeries. Some of our commercial carriers want the office visits billed under the physician and the assist at surgery billed under the dr. The rules vary depending on the commercial carrier, (and yes we do have all of this in writing either in our contract or from letters by our provider service reps.) For Medicare, Medicare replacements or carriers that do recognize the PA's we follow the incident to rules which can be tricky. You should be able to find incident to rules on Medicare's website. If this is an innocent mistake and they just arent sure how to bill they should be glad you are bringing this to their attention. Thank you!

  8. Default
    Quote Originally Posted by btadlock1 View Post
    Whoa, now...as it's been mentioned, be careful before throwing around the 5-letter "F-bomb". You could be mistaken about what you're witnessing (remember, you ARE new, and although this field is heavily regulated, and some of the regulations are clear, there are a LOT of exceptions to the rules that you may not be aware of; the laws are very complex, and often require legal analysis by an attorney to interpret accurately). Or, you could be absolutely correct, and are merely witnessing an innocent mistake from lack of knowledge.
    I'm home now and can respond a bit more. I apologize for not doing so quicker or giving alot of information.

    She also informed me that a portion of the time when this occurs, he is not even in the same office as the PA...therefore with just that alone, it would not be possible to code with the doctor on the claim based on the Medicare guidelines.

    I'd love to just ask the doctor and say "hey, let's refund Medicare", but he knows they pay more and that seems to be why it happens. The billing manager has informed him that he needs to be careful about this because "if Medicare checks, we could be in trouble". That night I went home and read many chapters on Medicare guidelines and what the rules were for PAs. I was pretty sure then I had a problem, but waited to verify the information at work. I've done that as many ways as *I* know how. I keep trying to prove myself wrong.

    Should I still talk to the doctor first? He'll be in tomorrow.
    Last edited by aprilsue; 01-03-2012 at 06:03 AM.

  9. #9
    Default
    I'd love to just ask the doctor and say "hey, let's refund Medicare", but he knows they pay more and that seems to be why it happens. The billing manager has informed him that he needs to be careful about this because "if Medicare checks, we could be in trouble".

    From the way you describe it appears to be done knowingly with the intention of seeking higher reimbursement.

    Medicare has very strict "incident to" rules requiring direct supervision by the physician.

    I would bring to his attention Medicare's policy on "incident to" billing and document such.

    "Incident to" is on the OIG's work plan for 2012 in a more expanded manner than previous years.

    If "incident to" requirements are not satisfied they should be billing under the PA at 85% reimbursement.

    As for no documentation found, billing for services that you can't prove by documentation were performed carries certain consequences.

    Maria
    Last edited by mcandia; 12-29-2011 at 07:55 PM.

  10. #10
    Location
    Concord, NC or Rochester, NY
    Posts
    154
    Default
    Before you go too far with any of this, the steps I would take are:

    1. Have a discussion with the billing manager to gain an understanding. Play a little innocent in that you are new and share the rules for Medicare Incident To Billing from your brief background. The next step depends on what happens in this dicsussion.

    2. If the billing manager somehow acknowledges there is an error and they do it because that is the way they were taught - then you have a teaching opportunity. If this is the case, then take a let's see what happens stand.

    2a. If the billing manager indicates this is done because it generates more money - now you have to go to the next step.

    3. Next step would be to get together with the doctor and share the concern. If there is a compliance person, you could also meet with them and share the concern. The next step here again depends on the attitude of the doctor/compliance person.

    4. If the doctor has the attitude it brings in more money, share with him that this is incorrect billing (do not use the word fraud at this point in time as that will get the MD very defensive). Indicate the correct rules but have the documentation in hand for the Incident To rules.

    5. If still nothing, then you have a personal decision to make: i) stay on but work with the insurance carriers to assist them as you could benefit from this; 2) resign and move on to another job ( I would not quit but start actively seeking another job and then jump ship ASAP); 3) bring it to the attention of the insurance carriers.

    From what you say is going on, check to understand the Incident To rules for each insurance carrier as they could all be a little different. Medicare is usually the most stringent. If they are actually changing the provider of service, this is fraud but again be careful using that word as fraud has to show knowledge and intent.

    Document every discussion and keep the notes at home. This is vital to your well being so that nothing comes back to haunt you down the road as they may try to blame you. If your system will show who made the changes in billing from a PA to an MD, get a few examples and keep these in your notes at home. You have to protect yourself in this escapade as many times the practice will try to blame the person like you that is trying to assist.

Page 1 of 2 12 LastLast

Similar Threads

  1. Fraud????
    By kassimayfield in forum Compliance General Discussion
    Replies: 6
    Last Post: 09-11-2014, 05:06 PM
  2. Fraud
    By poptart369@yahoo.com in forum Compliance General Discussion
    Replies: 1
    Last Post: 10-23-2012, 03:42 PM
  3. Is This Fraud?
    By dballard2004 in forum Medicare Regulations
    Replies: 9
    Last Post: 04-18-2012, 09:16 AM
  4. Possible fraud report
    By ded1982 in forum Compliance General Discussion
    Replies: 3
    Last Post: 10-19-2011, 04:03 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.