Wiki Fraudulent Billing

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BABS37

BABS37

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I have a general question and looking for some information.

My physician wants to bill out everything for services rendered to insurance even if there's a CCI edit or the cpt is defined as a separate procedure- everything regardless of all coding and billing guidelines per AMA and CMS. I informed him that this is fraudulent billing if he is aware the code combinations and surgeries going out are incorrectly billed. He still insisted he doesn't care and wants all codes to be billed out and to let the insurance decide what to pay for.

Can anyone advise me why this is not a good idea and where in writing does it say that this shouldn't be done and the consequences from this? I just don't think this is appropriate. This is why we have coders on staff reviewing and coding. Right?
 
Look on the OIG (office of the inspector general) website at oig.hhs.gov and then click on "Fraud" and then click on "Enforcement Actions" and then "Civil Monetary Penalties." There is fraudulent claim information there. Hope this helps.
 
The main point I would bring to him is the False Claims Act. Part of the OIGs Federal Registers definition of False Claims Act is "knowingly acts in reckless disregard of the truth"...... the examples they list are duplicate billing and "Unbundling or "exploding" charges.......

I hope this helps. This is not just a suggestion..... it is on the OIG radar and eventually someone will flag him.

Tammy Frazier, CPC, CPCO, CPMA, CEMC
 
Document everything !!!

Make a note of every conversation and the date you made with him informing him what should be done properly and legally... tell him he's putting his practice in red flag for an audit...

If everything fails, LEAVE !!! :rolleyes:
 
Thank you everyone! :) I know its wrong and have documented all conversations and emails as to why he can't- I just couldn't find it in writing in the right places to back me up on this so you guys ROCK!!!! Yay!!!
 
Hi,

You can also mention that insurance companies audit providers and flag those who repeatedly submit questionable claims. He may find himself in a position where EVERY single claim is either denied on the front end (and has to be appealed) or medical records are required for each and every submission (a very long delay on payment.)
 
With auto adjudication the carriers have the software to "flag" those claims that fall outside certain protocols (bell shaped curve)...I managed a pediatric practice where BCBS flagged my doctor for giving too many hepatitis A vaccinations....this same report also flagged him for $43 K in neonatal ICU charges. This was wrong as well because the baby was not his patient and the pediatrician was not a neonatologist. I called the person in charge who absolutely refused to make any corrections, even when presented with the overwhelming facts. It took six months to get these errors corrected.
 
I tried to explain the 'red flags' it would cause with insurance but that didn't help. I did send the link for OIG and let him know the reason why we don't submit billing this way and if he continued, he would be fraudulent billing according to The False Claims Acts (thank you Tammy) and would suffer civil penalties and that I surly wouldn't be a part of it.

That's the thing that bothers me the most- I understand that physicians want everything billed out and want paid for all services they do and that they worked hard to be where they are but seriously, I've worked hard to be where I am and no one is worth jeopardizing my career over either. I wish most physicians respected coders and realize that we are protecting them along with ourselves and that we, too, have a lot at stake. I just refuse to put myself into a risky situation and will walk away. Blah. Sorry for the rant.
 
fraud ramafications for billers

In the same subject my questions is; what are the ramification for a biller to submit charges to the insurance companies and Medicare knowing that is a violations of medical policy and Medicare, but the physicians refuses to follow the rules, is the biller accountable for the physicians reckless?.
I feel I need to change careers because these doctors don't get it...
 
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