# Need to report fraud, need some guidance



## AprilSueMadison (Dec 29, 2011)

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?


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## mitchellde (Dec 29, 2011)

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.


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## penguins11 (Dec 29, 2011)

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?


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## AprilSueMadison (Dec 29, 2011)

penguins11 said:


> 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.


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## mitchellde (Dec 29, 2011)

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.


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## btadlock1 (Dec 29, 2011)

himgirl said:


> 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.
> 
> ...




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.


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## penguins11 (Dec 29, 2011)

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!


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## AprilSueMadison (Dec 29, 2011)

btadlock1 said:


> 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.


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## mcandia (Dec 29, 2011)

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


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## mdoyle53 (Dec 30, 2011)

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.


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## jmarkey (Jan 11, 2012)

I have some experience addressing some of the legal issues arising in situations such as the one you describe.  Feel free to contact me (all communication kept strictly confidential) if you would like. Thanks--

jmarkey@bm.net


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## mengtan63 (Jan 19, 2012)

I am not sure what State your doctor is located or the type of patients, i.e., tranditional Medicaid, Medicare, or managed care, they serve.  In NY, under Medicaid (not managed care Medicaid), the supervising physician needs not be in the same office or location and they can supervise up to three PA/NP and can bill under the supervising physician's name, however, the PAs/NPs must not be registered with Medicaid to bill under their own ID (waive the right to bill).  By this account, you can see that different rule exists depending on the type of beneficiaries.  So, check your local guidelines in addition to Medicare guidelines.


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## Peter Davidyock (Jan 20, 2012)

Well put Michael. Cudos to you.

Incident To services are on the OIG's work list this year. So it's not a matter of "if" they look. They "are" looking.
My first job in this field was with a rather shady company. Luckily I got out unharmed. The owner is in jail, has been for the last couple of years now. I think he still has a few more to go.

What does the overall operation where you work look like?
Getting a lot of collection calls from vendors? Renting a lot of equipment?
Running outdated software on old computers?


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## coder1 (Jan 20, 2012)

This thread is very interesting. I'm reading Himgirl response stating that she spoke with the billing manager. The billing manager replies with the doc can get in trouble. I haven't heard a response to what she should do next? 

I noticed that some responses,  justify that you can bill under doc regardless if they was present at time of visit for certain carriers. Really???


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## sdeaton (Jan 20, 2012)

In Texas, a PA can perform services without the presence of the supervising physician.  PA is the "rendering" in box 24J of CMS-1500 and bills under the physician in box 31. The supervising physician could be providing services at another clinic (we have 5) on the other side of town, at same time/day as the PA.

Texas Occupational Code and Texas Medical Board set the rules for physician/PA relationship and delegation of work to the PA.  As long as the supervising physician is following those rules, it's perfectly legal.

Don't know what state you're in but it stands to reason that you should also familiarize yourself with your state's guidelines before jumping to any conclusions.


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## mitchellde (Jan 20, 2012)

Not to butt in here but.... When the Pa uses his NPI number in 24J then he is billing under himself and not the physician, and yes every state will allow the PA to do this and the physician must be reachable within a certain restriction which varies.  What most on this post are referring to is using the physician NPI in 24 J as the rendering when the physician did  not render nor was on site to supervise.  This you cannot do.


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## btadlock1 (Jan 20, 2012)

Some commercial payers will allow it PA's to bill as their supervising MD, as long as the charges are appended with a modifier to indicate that the services were actually performed by an NPP (SA modifier). They won't allow you to get around the fee reduction for NPP's, though - one way or another, you have to let them know it wasn't the doctor. (Check your provider manuals for payer policies on NPP billing)

Don't bill Medicare under the MD if the MD's not in the same building at the time, though - it doesn't meet incident-to requirements, and the issue is chronically on the OIG's hit list.


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## sdeaton (Jan 20, 2012)

mitchellde said:


> Not to butt in here but.... When the Pa uses his NPI number in 24J then he is billing under himself and not the physician, and yes every state will allow the PA to do this and the physician must be reachable within a certain restriction which varies.  What most on this post are referring to is using the physician NPI in 24 J as the rendering when the physician did  not render nor was on site to supervise.  This you cannot do.



My mistake was box 31... should be box 33. 24 J is "rendering" provider but 24J doesn't make that provider the "billing" provider.  The info in box 33 drives who's billing.  In my case, the group name and NPI.


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## mitchellde (Jan 20, 2012)

box 24J which matches the signature on 31 is the NPI of the one rendering or supervising the service, 33 is the practice the provider is credentialed with.  So when you use the physician NPI in 24J instead of the PA then you are "billing the claim under the physician"  representing the physician as the provider/supervisor  of the service.


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