Career Code Red: Unintentional Medicare Billing Fraud
While a number of high-profile cases of Medicare fraud—costing hundreds of millions of dollars each—have been reported in the media, there is speculation that a lot of the fraudulent activity that occurs within the health care system is actually the result of innocent or ignorant mistakes on the part of providers. If you think you're safe because you've never intentionally committed fraud, or you think investigations and audits aren't costly, you may need to brush up billing compliance—preferably before you code another file or sign another claim form.
To avoid the costs in time, stress, and legal bills (not to mention massive fines and possible jail time in egregious cases), Buppert emphasizes, “If you’re doing billing—especially if you’re in your own business, but even if you’re not—you need to know the requirements of Medicare, especially for documenting what you’ve done in order to justify the bill.”
For NPs and PAs, there may be an additional area of concern, depending on the state, the practice agreement, and their relationship with their supervising/collaborating physician. If they see billing practices in place that confuse them or make them uncomfortable, what can they do?
“Try to approach it in a way that’s a win-win for everybody,” Phillips suggests. “You’re not trying to accuse anybody or anything like that; you just want to make sure that everything is aboveboard, for everyone’s sake. You know, ‘I’ve been reading about issues with fraud and all these audits and how people are billing incident-to, and I just want to get a clear idea of how we’re doing that, so that we’re all staying out of trouble.’”
“If you know something is being done illegally, inappropriately, or fraudulently, there’s really not much question about what the appropriate response is,” Powe says. “However, what’s really important is, if there is some concern or question, at that point I think it should be raised with the supervising physician and there should be a checking of the rules and regulations.”
If the subject is broached with the intention of protecting the practice as well as the individual clinicians, there should be no objection to clarifying or reviewing billing procedures. “If protecting the practice is the basis upon which the question is asked,” Powe says, “we hope that will elicit the proper response from the supervising physician, who should also want to make sure that there are no inappropriate things occurring within the practice.”
And should the practice be engaging in illegal activities, make no mistake: There is an expectation that anyone with knowledge of fraudulent billing practices will report them through the Office of the Inspector General. “The government is leaning more toward ‘If you know there’s a problem, you can’t just sit by and let it go,’” Buppert says, although she cautions that clinicians should first try to address the issue internally and be sure their data is 100% solid before they turn in an employer.
Most NPs and PAs simply want to provide excellent patient care and be compensated for their services; they don’t want to police their clinical settings. But mistakes can be costly, and innocent errors are likely to increase when the threat of ICD-10 finally becomes reality. An ounce of prevention really can be worth a pound of cure—and sometimes, it can be what saves a career.
“Clinicians have to understand that their ability to maintain their license and practice clinically could be placed in jeopardy if there is an inappropriate use of billing mechanisms,” Powe says. “If fraud and abuse charges are brought upon them, that could eliminate their ability to practice.”
“All of us have an obligation, whether we are employed by somebody else, in government service, or self-employed, to understand the business of health care and understand these rules about getting paid,” Phillips concludes. “We have to get educated, because I think the rules are only going to become more complicated.”
