Optometry Coding & Billing Alert

Question: If an optometrist asked me to do something I knew was unethical or illegal--such as billing for an inappropriate level of evaluation and management service--and I was caught doing it, who takes most of the blame?


Michigan Subscriber

Answer: The physician is supremely responsible for your office's billing practice. However, the law can also hold billers and coders personally responsible for errors. And recent history suggests that state and federal governments--and commercial payers--will add billers and coders to the list of defendants in a billing-fraud lawsuit.

However, in billing-fraud lawsuits, the billers and the doctors are most always in a partnership to defraud the characters, showing a pattern of claim fraud. If there is a problem with only one or two claims, there is not likely to be a lawsuit.

Protect yourself from accusations and penalties by limiting your risk for these billing-law violations:

False claims: You might be guilty of a criminal violation if you knowingly submit a false claim or cause such a claim to be submitted. This applies not only to billing for services the optometrist did not provide but also to inappropriate coding, such as deliberate upcoding or misusing modifiers to secure higher payment.
 
And ignorance of the law is no excuse if you are accused of filing an illegal claim. You can be liable for a civil violation without even knowing it's illegal. (Prosecutors will say you should have known.)

Concealment: If you conceal information, or fail to disclose it, in order to secure payment, you can be directly liable. And you could be accused of conspiracy if you keep quiet when you know a doctor is intentionally coding incorrectly and concealing his misdeeds.

In court, prosecutors for the government or a payer can cite your lack of action as evidence that you-re in -agreement- to participate in concealment with a doctor or a doctor group.

Mail and wire fraud: Even if you don't sign or prepare a false claim, you may be the one mailing or electronically filing it. This can implicate you in a mail- or wire-fraud accusation.

Be a watchdog for your office. If you notice a problem that everyone else has overlooked, it's your responsibility to correct it. Document your actions in writing.