Medicare Compliance & Reimbursement

One Doctor Indicted in $33 Million Medicare Fraud Charges

Imagine how different your billings would look if an extra $22 million showed up in your account over an eight year period. You would probably be stunned at the windfall — but one practice in California is accused of considering it business as usual, and is now in hot water with the Department of Justice.

The physician allegedly billed Medicare for services that weren’t medically necessary, and sometimes billed for services he never provided at all. He also is said to have signed orders for medications, home health, hospice services, and durable medical equipment that were later sold to other entities so they could likewise create fraudulent billings.

After billing $33.4 million between Jan. 2006 and May 2014, the doctor allegedly collected over $22 million on those allegedly false billings, and the FBI and Department of Justice moved in for the arrest. The doctor was indicted on June 3 and charged with one count of conspiracy to commit health care fraud.

To read more about this case, visit www.justice.gov/opa/pr/2014/June/14-crm-596.html.

 Highlighting Your Documentation Can Be Good — But Not If Done Literally 

Don’t make things worse instead of better when it comes to medical review.

Problem: "Medicare encourages providers to take the initiative and review medical records prior to submission," says Part B MAC Palmetto GBA in a new question-and-answer on its website. "However, highlighting to draw attention to a specific part of the medical record may render the information unreadable."

Solution: "A better practice is to circle or mark the information with an asterisk," Palmetto advises.

To read this advice from Palmetto, visit www.palmettogba.com/palmetto/providers.nsf/DocsCat/Jurisdiction-11-Part-A~9JNJ2V8886.

 Check This Progress on Billing 69210 With E/M Codes 

If you’ve been frustrated by halted reimbursement for 69210 (Removal impacted cerumen requiring instrumentation, unilateral) with an E/M service, you’ll be glad to finally receive some good news on that front.

The scoop: Cigna has changed its policy regarding claims that include 69210 with an office-based E/M code (99211-99215). Any claim with these codes and modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) will be reprocessed by the payer. Going forward, Cigna will reimburse providers when they append modifier 25, with no documentation necessary with submission.

For more on this issue, visit the website of the American Academy of Otolaryngology-Head and Neck Surgery at www.entnet.org/content/news-and-updates-private-payers.