Wiki This is fraud right? Or am I losing my mind?

[leagle]

Our front office staff wrote a new order for physical therapy themselves and faxed it to the referring physician for signature because the original order that came over had a diagnosis code on it that wasn't covered by insurance. They wrote on it "we need the referral diagnosis to match the treatment diagnosis to be covered."

Rules state the order must have the patient's medical diagnosis on it. Therapists are not allowed to diagnosis patients in the state of Michigan, only MD or DOs can. We can't code something just to get it covered! We can't lead someone to a code. They've been told numerous times that they cannot do this, but they continue.

My question is this considered intent to deceive or not? I feel it is because they've been told it's not allowed and why. I think it's fraudulent but I'm being told it's not and just "an educational situation about proper communication."

Am I overreacting??? Compliance makes me nervous.

 

[csperoni]

I don't like to use the "f" word, but this is certainly wrong, even if it does not rise to the legal definition of fraud.
A one time error from someone who simply didn't realize how wrong it was, would be far less concerning than someone who has already been educated and continues this. Perhaps a compliant form letter to the referring physician carefully worded would prevent this moving forward and still allow your front desk staff to correspond with the referring physician without concern.

 

[leagle]

Thank you!

 

[CBLENNIE]

Our front office staff wrote a new order for physical therapy themselves and faxed it to the referring physician for signature because the original order that came over had a diagnosis code on it that wasn't covered by insurance. They wrote on it "we need the referral diagnosis to match the treatment diagnosis to be covered."

Rules state the order must have the patient's medical diagnosis on it. Therapists are not allowed to diagnosis patients in the state of Michigan, only MD or DOs can. We can't code something just to get it covered! We can't lead someone to a code. They've been told numerous times that they cannot do this, but they continue.

My question is this considered intent to deceive or not? I feel it is because they've been told it's not allowed and why. I think it's fraudulent but I'm being told it's not and just "an educational situation about proper communication."

Am I overreacting??? Compliance makes me nervous.

I'm asking the following questions purely insurance company's perspective, setting aside the issue that in Michigan only the MD or DO can diagnosis the patient.

If I'm understanding you correctly, the front office staff sent the new PT order to the referring physician due to a coverage issue for the DX on the original order. Did the staff member who added the "covered" diagnosis select a diagnosis that is supported in the patient's medical record, or did they simply select what they knew would be a covered diagnosis for the PT treatment?

Was the diagnosis selected a condition for which the PT treatments would be medically necessary and the standard of care for the patient's condition. I am a compliance specialist for a commercial insurance company, we also offer MA plans and administer Medicare Medicaid dual eligible plans as well and work closely with our Special Investigations Unit (SIU). It is quite concerning that a diagnosis is being changed just to get the services covered and my concerns grow exponentially if the diagnosis is not supported in the medical record. Even if the medical record supports the diagnosis on the new PT order, is the PT being performed to treat the diagnosis on the PT order?

If the PT isn't being performed for the diagnosis listed on the new referral and subsequent claims, this is would be a serious issue for our SIU department and would likely bring scrutiny to the PT practice that could result in a pre-pay or post-pay audit. Let's be honest if it did prompt an audit, more than likely payments are going to be recouped and for insurance companies that administer MA plans it would have to be reported to CMS for further investigation of the PT practice as a whole.

This situation is messy at the very least and I don't blame you for being concerned about compliance issues.

On a side note, I wonder if the MDs & DOs who are signing off on these new PT referrals realize that they are potentially putting themselves at risk with CMS, as well as the state licensing board because they are allowing someone other than themselves to diagnosis their patients.