ED Coding and Reimbursement Alert

Scrutinize your compliance program to avoid such issues.

As healthcare auditors increasingly add new issues to their review lists, emergency departments have remained vigilant, buttoning up their documentation and recordkeeping. If you’d like some insight into the types of cases being prosecuted in this specialty, we’ve got the details of three ED-specific issues that were brought to light over the past few months which can help you determine what not to do if you’d like to avoid fraud.

1. Performing Procedures Outside Scope of Practice

A North Carolina emergency physician was under scrutiny by the state medical board for performing surgeries outside of his scope of practice. Although he was a board-certified emergency medicine specialist, he eventually segued his career into performing cosmetic surgery and other surgical procedures, which led to a suspension of his medical license for a period.

His license was ultimately reinstated under specific conditions, including a restriction to now limit his practice to the emergency medicine and urgent care specialty areas. He is no longer allowed to perform surgical procedures outside that scope of practice, and cannot perform any cosmetic procedures.

The takeaway: State scope of practice laws dictate which services health care professionals are able to perform in each state. It’s imperative to not only follow the regulations that Medicare and other payers release, but to also know your state laws and to adhere to them carefully.

2. Filing False Claims

In March, two California urgent care physicians were charged with eight felonies for filing false claims to insurers. The clinic in question was audited, revealing a “100 percent error rate for billing, including upcoding – falsely claiming a more serious injury or illness – and billing for services not rendered,” said prosecutors in the charging documents.

The overbilling was so egregious that in one situation, a patient presented to the urgent care clinic for job-related drug testing, but the clinic billed the patient her copay – and then sent a claim to the insurance company for $425, stating that the patient had a urinary tract infection, which was false.

The takeaway: Physicians are responsible for the medical decisions they make, so erroneously (and willfully) administering or prescribing care for patients who don’t have a medically necessary reason for the service is problematic. Not only will it hurt insurers by overcharging them, but it isn’t a sound medical practice, as patients shouldn’t be treated for conditions they don’t have.

Tip: Remember, Medicare defines medically necessary services as “healthcare services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.” And the best way to demonstrate medical necessity is with thorough and accurate documentation. If the medical record does not support the service(s) billed, CMS can certainly recoup the funds paid to the provider.

3. Unwarranted ED Facility Charges

In September, the Department of Justice charged a Florida hospital chain with fraud after the hospitals created a plan to boost inpatient admissions from the ED, even if such admissions were not warranted.

The chain was said to have “pressured emergency room physicians, including through threats of termination, to increase the number of inpatient admissions from emergency departments – even when those admissions were medically unnecessary,” the assistant attorney general said at the time. The chain had to pay over $260 million to resolve the charges.

The takeaway: If your ED hears similar requests from the hospital, be wary. It’s always your responsibility to ensure that claims or orders with your signature are accurate and medically necessary.