Ophthalmology and Optometry Coding Alert

You thought billers couldn't be held responsible? Think again.

Medical coders and billers are well aware of the fact that physicians are responsible for the codes that they report to insurers - but that doesn't absolve the billing staff of fraud accusations, or prison sentences. That's the word from a recent case involving a medical biller in Michigan who headed to prison for a 50-month sentence earlier this summer.

Background: Medical biller Dawn Bentley was sentenced to 50 months behind bars for her part in a $7.3 million fraud scheme that involved billing services to Medicaid and Medicare, even though the services were not rendered. The biller must also pay $3.2 million back to the federal health care program.

Check in With Billing Services

Although the case above appears to have involved a biller and a physician that were conspiring to overbill insurers, there have been situations where billers "go rogue" and misbill insurers without the medical practice's knowledge. Likewise, billing services should be sure to keep an eye on medical practices to ensure that they're documenting and coding appropriately. Check out the following tips to ensure that both the medical practice and the biller are well-protected from fraud accusations or other suggestions of wrongdoing.

1. Ensure That They Understand Both Medical And Vision Plans

Although most medical specialties might be able to hire a generalized billing company, eye care practices should ensure that their potential billing and coding consultants have experience with vision plans, says Richard S. Kattouf, OD, DOS of Kattouf Consulting Services, Inc. "Most medical billing and coding companies will understand how to bill medical insurance, but if you want the company to do your vision billing in addition to your standard insurance coding and billing, you'll want to find a company that has experience with that rather than just experience with medical insurance," Kattouf says. "That's because vision plans have their own nuances."

If you hire a billing company that has no understanding of eye care plans, there's a chance the billing firm could improperly report services to the medical plan that should be billed to the vision plan, or vice versa.

2. Ensure the Service Is Well-Versed in Compliance

Any billing service should be able to identify occasions of improper billing, so the service should know what to do if it uncovers instances of coding or billing problems. In fact, some billing services will even help the medical practice with its compliance program.

"We create a compliance manual for each clinic that hires us to do their billing, and it contains the seven chapters the OIG wants in there," says Bonnie J. Flom, CEO, CMRS, CCCPC, of Billing Buddies in Minnetonka, Minnesota. "We create the basic compliance manual and then I tell my clients that they need to keep working on it over time as new rules come out and changes are issued."

Because the billing firm and the medical practice are on the same side when it comes to compliance, any billing service that doesn't have compliance at top of mind may not be the right fit for an eye care office. "I want to audit-proof our providers," Flom says.

3. Check the Fee Arrangement

Another potential red flag that medical practices should heed when assessing billing services involves how they invoice the practice, Flom says. The OIG suggests that third-party billing services could violate the anti-kickback statute if they take a percentage of the money they collect on behalf of medical practices, and many state laws forbid that as well.

"When a medical practice calls me and asks about our billing service, it's a tipoff to me if the place they're with now or considering hiring is taking a percentage of their billings. That tells me they're not very up to date on rules or regulations," Flom said. "A lot of medical practices will call because they're comparing prices of different billers, and many are of the mindset that they want a practice to take a percentage, because if the biller doesn't do their job, they don't get paid. But in the OIG's mind, billers that take a percentage could have an inducement to miscode or upcode so they'll get more money."

Therefore, medical practices should aim to work with a billing company that charges a flat fee rather than asking for a percentage of billings.

4. Find Direct Account Rep.

If the medical practice contracts with an entire billing firm, it can be hard to pinpoint who to contact if an issue arises. Therefore, Kattouf recommends that each eye care practice work directly with a specific contact at the billing company so you always know who you can get in touch with if you have questions about your account.

"It's very important to have a check and balance system, whether your billing and coding are in-house or external," he says. "We assume the billing company is looking at EOBs, and if the claim is denied we assume they're resubmitting - but the only way to know for sure is to check in with them frequently. And if you have a key contact at the company, it's much easier because you can call and say, "Hi Susan, can you tell me where we stand on A/R today?'" Otherwise the alternative is getting transferred from one person to the next before you determine who handled your claims that day.

"That type of follow-up is a big piece of the puzzle," Kattouf says. "It allows the doctor to keep a pulse on their practice, which is very important to the success of your billing and coding program."

5. Maintain A "Check-In" Arrangement

The biller and the medical practice should be checking in with one another frequently, and any biller that only wants to talk to the medical practice on a set schedule (say, once a month) should be avoided.

"The medical office and their point of contact should be speaking often, but they also should know that if there's ever an issue or question, that the phone lines are always open," Flom says. Neither party should have to wait until a monthly meeting to bring up concerns, she advises.