Could this be fraud?
I have a concern that I've been looking into for a little over two months now with a company I am in business with. The problem I've seen is that their claims are getting denied by medicare due to the referring providers not being enrolled or not being eligible to order or refer for medicare patients. However, once the claim is denied there is a regular practice of assigning the NPI of a different provider that is enrolled with medicare on that same claim and resubmitting it as a claim correction so it will get paid.
I've found a number of articles that talk about this and I know that reporting for services that you didn't actually provide is definitely fraud. I don't know if this is the same thing though, I've also only been certified for a short time so I'm not an expert by any means. I'm just a little worried that this is a bigger compliance issue than what the organization understands and could potentially put me and my licenses at risk if I continue my involvement with this company. I've brought up my concerns with the organization and helped create an action plan to change these practices but I'm still seeing it blatantly being done regardless of the steps taken to stop it.
I feel obligated to report this but when I contact CMS or HHS directly to ask questions they are helpful but both have told me they can't say what is fraud or what isn't they just take the reports, so I'm looking for advice and opinions on what others have encountered, how they handled it, and what you think I should do in this situation.
Any advice with this is greatly appreciated.
I have a concern that I've been looking into for a little over two months now with a company I am in business with. The problem I've seen is that their claims are getting denied by medicare due to the referring providers not being enrolled or not being eligible to order or refer for medicare patients. However, once the claim is denied there is a regular practice of assigning the NPI of a different provider that is enrolled with medicare on that same claim and resubmitting it as a claim correction so it will get paid.
I've found a number of articles that talk about this and I know that reporting for services that you didn't actually provide is definitely fraud. I don't know if this is the same thing though, I've also only been certified for a short time so I'm not an expert by any means. I'm just a little worried that this is a bigger compliance issue than what the organization understands and could potentially put me and my licenses at risk if I continue my involvement with this company. I've brought up my concerns with the organization and helped create an action plan to change these practices but I'm still seeing it blatantly being done regardless of the steps taken to stop it.
I feel obligated to report this but when I contact CMS or HHS directly to ask questions they are helpful but both have told me they can't say what is fraud or what isn't they just take the reports, so I'm looking for advice and opinions on what others have encountered, how they handled it, and what you think I should do in this situation.
Any advice with this is greatly appreciated.
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