Avoiding the RAC: Expert advice


The vast majority of physicians at the center of billing investigations and audits have made accidental errors. Regardless of intent, however, such mistakes fuel lengthy examinations, fines, and, in some cases, civil or criminal charges.

"The overwhelming majority of physicians are good, honorable people trying to take care of patients to the best of their ability. Having said that, ignorance is no excuse" for billing errors, said Mark S. Kopson, chair of Plunkett Cooney’s Health Care Industry Group in Bloomfield Hills, Mich.

Proactive steps to ensure correct billing and recognize early any errors are essential to preventing investigations and defending overbilling accusations, said Heather Greene, vice president of compliance services at Kraft Healthcare Consulting in Nashville, Tenn.

At the February meeting of the American Health Lawyers Association (AHLA) Physicians and Hospitals Law Institute, Ms. Greene discussed recent trends among False Claims Act (FCA) claims and reviews by Recovery Audit Contractors (RACs).

More claims are being seen related to incorrect unit billings for medications, multiple procedures erroneously coded together, and incorrect usage of modifiers, she said. Also, auditors and investigators are quick to scrutinize cases in which physicians fail to clearly link the patient’s presentation to the diagnosis and treatment provided.

"The overarching criteria for all services is medical necessity," Ms. Greene said. "Medicare says it’s the physician’s responsibility to substantiate that treatment was medically necessary. If they don’t write it down, if they don’t connect the dots, then medical necessity could be called into question."

A critical element in avoiding government scrutiny is maintaining a solid compliance plan, said Mr. Kopson. The plan should include regular self-auditing and the comparing of a random sampling of charts to submitted claims.

"If you don’t have the time or expertise in-house to do that, contract with an outside consultant," Mr. Kopson said. "That will be money very well spent."

He also advised ensuring that billers and coders are appropriately trained and have sufficient skill and experience to bill accurately.

Once a payment error is identified, the claim must be refunded within 60 days and the claim must be self-reported if any fraud is involved, said Christopher A. Melton, a health law attorney and partner at Wyatt, Tarrant & Combsin Louisville, Ky. But Mr. Melton notes that federal rules lack clarity on the scope of identification. For example, if 10 claims are examined and the same error is found in all of them, it’s unclear if that sample accounts for the identification of all similar claims submitted, he said.

"The problem is, no one can audit 100% of their charts," said Mr. Melton, who was copresenter of the AHLA session. "Is there a duty to look deeper into these? Those are the questions everyone is going to have to wrestle with."

Nearly as important as preventing billing mistakes is handling audits and billing investigations correctly when they happen. While such examinations can be nerve-wracking, remember to stay calm and refrain from changing or trying to improve records, Mr. Kopson said.

"Do not change any medical records, period," he said. "That is the surest way to lose your audit or civil case and [create] significant risk of incurring criminal liability or licensure sanctions. I’ve seen far too many people get the notice, go into panic mode, and start rewriting history."

If it’s necessary to augment a chart, follow the proper rules for making amendments and additions to notes.

When physicians disagree with the findings of a RAC audit, they should document the dispute and their concerns, even if they chose to repay the claim, Mr. Melton said. This helps strengthen a doctor’s case should there later be an FCA or fraud accusation.

The aid of an experienced health law attorney can allow one to work competently through audits and address overbilling allegations, Ms. Greene added.

"Just like health care, this is a very complex industry," she said. "It’s helpful to have an attorney involved. Sometimes attorneys can have conversations with government attorneys and ask questions physicians may not be able to ask. They have a toolbox that is set up to deal with these kinds of situations."

Mr. Kopson stresses that physicians must accept that "the buck stops" with them when it comes to proper billing and coding.

"It’s no defense that your clerk entered inaccurate information or someone else who was employed by your employer did the coding," he said. "It’s critically important that you know what they are billing for your service. You could wind up in the hot seat very easily. Know the required elements for your most frequently billed codes ... and ensure that you’re documenting accurately all of those elements that you’re performing."

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