Medicare Compliance & Reimbursement

The Department of Justice (DOJ) continues to crack down on fraudulent E/M claims. The law clearly states that “providers are not permitted to bill both E/M services and a procedure on the same day under the Medicare program’s regulations unless a significant, separately identifiable service has been performed.”

But in one recent case, a group of Georgia dermatologists repeatedly “upcoded E/M services to higher levels than were appropriate, leading to overpayments by Medicare.” The practice was found guilty and is forced to pay back the false claims — $1.9 million — under the False Claims Act, an April 18 DOJ news release revealed.

The Centers for Medicare & Medicaid Services (CMS) maintains that a thorough understanding of the law is a good place to start to avoid overbilling. Other suggestions under their report, Avoiding Medicare Fraud & Abuse: A Roadmap for Physicians, include taking detailed, readable notes, providing practice education and training, and performing in-house audits.

Lawbreakers like these not only hurt themselves, but by abusing the system, they make it more challenging for other physicians and the patients themselves.

“The improper billing of evaluation and management services cost the taxpayers millions of dollars each year and drain the Medicare Trust Fund,” said Derrick L. Jackson, an HHS Office of the Inspector-General (OIG) special agent, in the news release. “The OIG and the U.S. Attorney’s Office will continue to hold health care providers like these responsible for improper claims.”

Resource: To read more about these E/M false claims, visit www.justice.gov/usao-ndga/pr/dermatology-physicians-and-practice-pay-19-million-settle-false-claims-act.