Practice Management Alert

We'll show you how to protect yourself from committing these 3 billing-law violations

Bad news, billing-office staff: Your billing mistakes and oversights can put you on the hook for legal fees, fines, and even jail time, not to mention the possible loss of your job.

Even though the physician is the ultimate overseer of claims, the law can hold billers and coders personally responsible for errors, says attorney Wayne J. Miller with the Compliance Law Group in Los Angeles. 

Recent cases show that the state and federal governments, as well as commercial payers, "are not afraid at all" of adding billers and coders to the list of defendants in a billing-fraud lawsuit, says Miller, who presented at a recent Coding Institute teleconference.

To protect yourself from accusations and penalties, you must work day-to-day to limit your personal-responsibility risk for these billing-law violations:

False Claims

You can be liable for 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 not rendered but also to inappropriate coding, such as deliberate upcoding or misusing modifiers to secure higher payment. You can even be liable for a civil violation if you submit a false claim without even knowing it's illegal. Prosecutors will say you should have known.  

Concealment

You can be directly liable if you conceal or fail to disclose information in order to secure payment. And you could be accused of conspiracy if you keep quiet when you know a doctor is intentionally coding incorrectly and concealing his misdeeds. 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're not the one signing or preparing a false claim, you may be the one mailing or electronically filing it.  This can implicate you in a mail- or wire-fraud accusation.
 
Protect Yourself!
Don't be passive about your billing and coding, Miller says. Take these proactive steps: 

Speak up when you think something isn't being done correctly and bring it to the attention of your compliance officer, billing manager or practice manager.

Show that you're keeping up-to- date with current CPT and compliance standards by using current coding books, reading coding and billing publications (such as this one!), and attending education sessions.

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


Decrease Your Office's Liability

Reporting misconduct "places you in a crucial decision-making position," says Brenda Burton, president of MedExtend Inc. in Fayetteville, Ga.

While you don't want to be passive, you also don't want to be overzealous by not following your organization's chain of command, she says. 

First, you should try to resolve compliance problems internally, Miller says. If you get no results after several attempts and you feel that what's going on is too illegal to remain unaltered, consider seeking outside help from legal counsel. "Don't go it alone," Miller says.

To help employees with compliance, the Office of the Inspector General recommends that practices do the following:

1. Construct and implement a written billing compliance program.

2. Designate a compliance officer and committee.

3. Train staff on what is involved with compliance.

4. Conduct routine internal audits to nip problems in the bud. (See "5 Surefire Strategies to Boost Your Internal Audit Integrity" this issue)

5. Encourage good communication between physicians and staff and enforce policies through well-known disciplinary guidelines.

"Two important factors play hand-in-hand: education and communication," says Burton, who also presented at the teleconference.

- Have employees acknowledge their part in compliance by signing statements of understanding.

- Post reminders around the office to make the compliance message clear.