# Legal question



## rubisaavedra (Sep 2, 2014)

Hello I am looking for some advise...I have a new doctor that is a surgeon and has told me that the NCCI edits do not apply to him because he is Not contracted with any insurance company at the moment.  I have stressed the need and value to having the edits available in his billing program. He is having me work on claims and submit how he wants them submitted, with like 15 codes for everything Done during surgery..unbundling several procedure codes. I have documented my conversations with him..I own my own billing company and recently became certified. Is there something else I can do to protect myself if and when he does get audited and he is requested to refund monies that he already paid me for the work that I did? (My percentage agreement)?
Any legal advise would be very helpful. Thank you!


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## AC32333 (Sep 2, 2014)

From the American College of Emergency Physicians (ACEP) FAQ page:

"Private payers use a combination of NCCI/CCI edits and proprietary edits to determine ?covered services? in accordance with payer benefit plans.  Payer payment policies frequently draw from CPT, NCCI/CCI and Medicare as well as applying payer-specific proprietary edits.  Thus, NCCI/CCI may be used by private payers in some form, but often NCCI/CCI is only one of a number of tools utilized by private payers to determine separately covered services."

http://www.acep.org/content.aspx?id=48111


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## Bready (Sep 2, 2014)

Although he is not a contracted physician, he might still be subject to the false claims act if he submits a claim for a Medicare patient.  Unbundling procedures for payment comes under the False Claims Act.  To protect your company, you might want to contact the OIG or a medical attorney. You want to be sure that every claim your company files is both accurate and in compliance.


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## MarcusM (Sep 2, 2014)

Just because he is not contracted does not mean the carriers won't process like they always do, and they will deny claims that are unbundled just like a contracted provider.  They will also looks at his claims with them if he does want to become contracted and may not contract with him due to excessive charges/codes.


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## rubisaavedra (Sep 3, 2014)

Thank you!


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## rubisaavedra (Sep 3, 2014)

Bready said:


> Although he is not a contracted physician, he might still be subject to the false claims act if he submits a claim for a Medicare patient.  Unbundling procedures for payment comes under the False Claims Act.  To protect your company, you might want to contact the OIG or a medical attorney. You want to be sure that every claim your company files is both accurate and in compliance.



is there a specific link to OIG? it seems the doctor is willing to put something in writing, stating he was given information on how claims should be filed, using ncci edits, and that he is making the final decision on how claims should be filed..but, does this still make me liable?  knowingly billing out claims that have cpt codes that are 'unbundled'?


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## mitchellde (Sep 3, 2014)

Yes it does!  To do something you know is incorrect just because you were directed to do it is still wrong and you are still liable.  You cannot sign away liability and no one can take it for you.


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## Bready (Sep 4, 2014)

*Legal Question*

Debra is correct.  There is always the possibility that you could be held responsible for filing claims that you knew to be incorrect regardless of anything you have in writing from him.

Marcus is  correct in that the insurance companies (who employ coders)will process the claims for payment according to the correct guidelines regardless if the provider is contracted or not.  Once in awhile the provider may be paid for a procedure that was unbundled, but during an audit this will be found and refund requested from the provider.  

OIG can be found at www.oig.hhs.gov

All the best.
_see it own it solve it do it_


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## jdyoutsey (Sep 4, 2014)

Contracted or not the guidelines are still the guidelines.


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## rubisaavedra (Sep 4, 2014)

mitchellde said:


> Yes it does!  To do something you know is incorrect just because you were directed to do it is still wrong and you are still liable.  You cannot sign away liability and no one can take it for you.



 I truly appreciate the information. I will be having a conversation with this doctor and I likely doubt he will want to keep me signed on to his practice.
Thank you all.


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## AB87 (Oct 9, 2014)

Also remember under the False Claims Act that "knowingly" breaks down into having knowledge of the info being billed. (Your a Coder/Biller) So you would have knowledge of the information. I would Cancel that Contract, Too much liability.


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