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Practice Management Alert

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Stay on the Lookout for Impossible Time

Published on Tue May 16, 2023

Hint: ‘Suspicious’ time can be a red flag.

Ensuring your clinicians are paid for their work is a top priority, but how do you make sure that neither you nor your providers fall into the “impossible time” trap?

Knowing how time is audited is one way to make sure you’re maximizing reimbursement while also complying with reporting and billing regulations and requirements.

Define Impossible Time

Billers, auditors, payers, and other folks looking at how much time clinicians spend with patients are evaluating whether the amount of time reported is probable — or even possible. This concept is called by a few names, including impossible time, improbable time, and an impossible day.

The Healthcare Fraud Prevention Partnership (HFPP), a voluntary, public-private partnership between 284 entities, shares information and data concerning healthcare fraud. As part of the HFPP, the Centers for Medicare & Medicaid Services (CMS) and other federal agencies, and commercial carriers, have zeroed in on impossible time in their evaluations of coding and billing waste, fraud, and abuse. The COVID-19 pandemic renewed their focus on impossible time.

The U.S. Department of Health and Human Services (HHS) and Office for Inspector General (OIG) have brought enforcement actions against individual physicians for Medicaid and Medicare fraud, respectively. Commercial payers also investigate, audit, and even hit organizations with sanctions or penalties.

Understand How Payers Audit Time

Generally, payers don’t know how many patients a practitioner sees during a day because most organizations see patients with different insurance carriers. Payers end up evaluating the reasonability of a practitioner’s time spent with a patient by comparing individual clinician’s reports with other reports of the same service, a process called outlier detection.

However, the data available for outlier detection is limited, because the sample of patient reporting available per practitioner is inherently small. And, as for impossible time, payers or auditors cannot access enough information to really evaluate how a practitioner allocates their time.

“In my experience working on the payer auditing side, there’s only one way that a payer would be alerted to a potential problem regarding time, and that is if the provider is billing a single payer for a number of services that far exceeds the amount that an individual could possibly perform in a given time period. But even this is not 100 percent reliable, because, under ‘incident to’ billing, a physician may be billing for multiple providers under their own credentials,” says Thomas Field, CPC, CEMC, a healthcare economics consultant.

With this in mind, one of the aims of the HFPP is a space for member entities to pool and share their data, boosting their collective chances of detecting fraud, according to expert witness testimony provided to the U.S. House Ways and Means Committee Subcommittee on Oversight by Alec Alexander, then deputy administrator and director, center for program integrity at CMS.

“The HFPP provides visibility into the larger universe of healthcare claims and claimants beyond those encountered by any single partner. The ultimate goal of the HFPP is to exchange data and information to improve detection and prevention of healthcare fraud,” he said.

Go By the Book, Beware the Consequences

Avoiding reporting impossible time is simple: Support all of your time reporting with the proper documentation. And make sure the numbers add up.

Reporting impossible time therefore seems easy to avoid. But what about what some experts call “suspicious time?” If your provider reports seeing four new patients for 45 minutes each, and 12 established patients for 30 minutes each, the total time spent with patients doesn’t exceed 24 hours, but the reporting also doesn’t seem accurate.

“The real suspicious part here is that every new patient is 45 minutes and every established 30 minutes. I would actually find it less suspicious if those four new patients were documented as 46 minutes, 52 minutes, 47 minutes, and 51 minutes,” says Christine Speroni, CPC, administrative office manager at NHPP Gynecologic Oncology in Ronkonkoma, New York. “While the insurance company would not have access to all 20 records, your internal people (like compliance) certainly do. Time documentation that is suspicious then casts a dark shadow on everything else.”

HFPP entities are comparing notes and doubling down on fraud investigations, as are federal agencies, who have a history of bringing enforcement actions against bad actors. In 2016, a physician, Barry Solomon, agreed to pay $300,000 to resolve civil claims brought under the False Claims Act. Among other false claims charges, the government presented evidence that he billed Medicare for 26 hours of work during a 24-hour period.

In March 2023, two people were charged with overbilling Medicare and Medicaid for patients’ addiction treatment counseling sessions after reporting time spent with patients that did not reflect the actual time spent. In a press release (www.justice.gov/usao-ri/pr/operators-addiction-treatment-chain-charged-alleged-health-care-fraud), the U.S. Attorney’s Office in the District of Rhode Island says, “At times, so many counseling sessions were billed at this level that the total amount of time would be impossible for the available therapist to have provided in any 24 hours period.” Although this case is still making its way toward resolution, the government is seeking damages: “The government is also seeking to forfeit thirteen bank accounts, two buildings, and two vehicles allegedly realized by the defendants as a result of the alleged criminal conduct.”

Note COVID-19 Focus

Federal and regulatory agencies, as well as Congress, moved to waive certain requirements around telehealth during the public health emergency (PHE) for the COVID-19 pandemic. Fraudsters saw opportunity in these loosened regulations.

The HFPP released a white paper, “Fraud, Waste, and Abuse in the Context of COVID-19,” noting that impossible time, especially surrounding telehealth billing, seemed problematic, especially in the psychotherapy and psychiatry specialties.

“One HFPP Partner indicated that, prior to the COVID-19 PHE, 99.3% of mental health visits occurred in-person, while after its onset only 56.0% occurred in-person. Given this shift to telehealth, several HFPP Partners described an increase in detection and investigations of impossible days,” the white paper says. However, other investigations of the available data suggest that the uptick in billing may correlate with compliant incident-to services.

Bottom line: When you’re reporting the time practitioners spend with patients, make sure the numbers and codes genuinely reflect the services provided — and the time spent doing so.

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