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Improper Billing and Testing Results in Fines and Jail Time for Providers

Improper billing and testing can result in fines and jail time.  The government is taking a very aggressive stance.  Providers beware!

Most providers aren’t even aware that they may be guilty of improper billing.  Many times providers appear before the courts and say they didn’t know.  Unfortunately, they soon learn that ignorance is not a defense.

Two recent cases underscore the importance of making sure the provider listed on the claim submission form is the same provider that performed the services, and the same one who documents and signs the medical note.

April was a busy month for the U.S. Department of Justice (DOJ). Two settlements highlight the notion that the U.S. government has a low tolerance for providers who defraud its programs such as Medicare, Medicaid, TRICARE, and the Federal Employee Health Benefits Program (FEHB).

Garrett Okubo (Honolulu) 

According to the DOJ, Garrett Okubo, the owner and operator of a physical therapy business in Honolulu, submitted claims for physical therapy services between January 2011 and October 2017 for payment from Medicare, Medicaid, TRICARE, and the Hawaii Medical Service Association. Okubo, in violation of 18 USC § 1347, executed a scheme by “falsely stating that Okubo himself had personally provided the physical therapy services to his patients, when in reality the services were provided by Okubo’s unlicensed staff members, including at times when Okubo was traveling on the U.S. mainland or in a foreign country.”

Although Okubo is not a physician, the issues raised in his case, which resulted in both monetary penalties and jail time, parallel those of improper billing of non-physician providers (NPPs) such as physician assistants, nurse practitioners, and clinical nurse specialists.

In general, Title 42 must be consulted regarding the scope of the reimbursement. If a nurse practitioner, for example, is billing under their own Medicare provider number, then the reimbursement by Medicare is 85 percent of the Medicare Physician Fee Schedule. It is also imperative to read the respective state law in order to ascertain the scope of practice, licensure requirements and level of supervision.

Biotheranostics, Inc. (San Diego)

According to the Acting Assistant Attorney General of the DOJ’s Civil Division, “laboratories that knowingly submit claims for non-reimbursable services will be held accountable.”

On April 19, Biotheranostics, Inc. agreed to pay $2 million to resolve allegations that it both submitted and caused to be submitted Breast Cancer Index (BCI) tests for Medicare reimbursement. These tests were not “reasonable and necessary” and, therefore, failed to meet the medical necessity standard.

The Medicare statute expressly states that laboratory tests may be reimbursed by Medicare only if they are “reasonable and necessary for the diagnosis or treatment of a patient’ illness or injury.” Relying on evidence-based medicine standards, the DOJ determined that the BCI test was being performed on breast cancer patients who neither had been in remission for five years nor had been taking tamoxifen. Therefore, substantiating that a number of claims that were submitted for Medicare payment were unauthorized and unnecessary.

The take-a-ways for physicians are as follows:

  • Make sure that NPPs are billing in the appropriate manner in conjunction with state and federal law and that the definition of “supervision” in a respective state is understood;
  • The person’s name on the claim’s submission form needs to be the one performing the service and indicated in the medical records;
  • Ensure that the diagnostic tests or treatment being order is substantiated by medical necessity; and
  • Failing to be compliant can and often does result in False Claims Act cases, which can carry both civil and criminal penalties.

 

By: Rachel V. Rose, JD, MBA. 
Rose is an attorney who represents and advises both corporate clients and individuals on healthcare, cybersecurity, securities, False Claims Act and Dodd-Frank causes of action.  She is also a Principal at Rachel V. Rose – Attorney at Law, PLLC, who also teaches bioethics at Baylor College of Medicine.

5 Common Reasons Your Claims are Bouncing Back

Billing is a complex and often tedious procedure, especially with ICD-10 codes. However, the reasons for returned and delayed claims often boil down to a few basics. Here are some of the most common billing mistakes practices make, and how to make sure your practice avoids them.

  1. Little Typos, Big Headaches

    Often reimbursements are delayed or denied because of very small, easy-to-make mistakes. “When I was assistant director of billing for a large multi-specialty practice,” says Brennan Cantrell, “the front office would often transpose the numbers or letters in policy number or omit a group number or plan ID. The front desk is extremely busy, and these are easy mistakes to make.” Cantrell, who is now commercial health insurance strategist for the American Academy of Family Physicians, says that the ideal solution is having an employee dedicated to watching for and correcting these errors. For small practices, this may not be a full-time employee, and the time saved by not having to resubmit claims might offset the time spent rooting out mistakes.

  2. Something’s Missing Here

    Sometimes payers delay payment because you didn’t send enough information. Often you can see this coming. “For example, when you file workers’ compensation claims, you will always need to submit documentation with the claim,” says Tammie Olson of Management Resource Group, an Ocean Springs, Miss., a firm offering financial management and support services for the healthcare community. “If you know you need to send the documentation to get a claim paid, do so when you file.”

  3. Please Ask First

    Another incredibly easy—but costly—mistake is not getting prior authorization. “Before you perform procedures, make sure you verify whether or not a prior authorization is required,” says Olson. “If it is, send in the request before scheduling the procedure.” And when you get ready to bill the procedure, “make sure the authorization number is on the claim,” she adds. Prior authorizations can be a pain, but having a routine for them when they are necessary can save time and prevent payment delays.

  4. Let Me See that One More Time

    Claims are increasingly denied because the patient’s coverage has been terminated or the plan or payer has changed.  Most of the time everything is just as it was the last time the patient came in but you should still ask to see the patient’s insurance card at every encounter. “People change insurance plans more often than they used to,” says Cantrell. “It’s a simple thing, but important.” Olson agrees, and adds, “If you do this, you should never have a claim denied for “policy terminated.”

  5. Keep up with the Changes

    Even when policies haven’t changed, what is and is not covered on a given plan sometimes does. You can be left holding the bag if a payer changes its policies about what procedures they cover or what labs they use, and you don’t hear about it. “Most payers send out a policy bulletin announcing these changes,” says Cantrell, “but it’s difficult to find time to keep up with this.” Large practices often have administrators who watch for these changes and pass the word on to each billing office. However, in smaller practices that job may fall to the front desk or billing staff. Make sure whoever does this understands the importance of carefully reviewing these bulletins when they are issued.

 

By: Avery Hurt

Ms. Hurt is a freelance writer based in Birmingham, Ala. Her work has appeared in publications including Newsweek, The New Physician, Muse, Parents, USA Today, and the Washington Post

Three Coding Updates – Provider Beware

Coding

CodingCODING IT RIGHT

We know everyone is busy and there is no way you can read every single article that comes in your inbox or crosses your desk.  So we thought we’d share three bullet items regarding coding that may impact your practice.

  • New Vaccine Codes for 2018

Medicare has announced a coding change.  After January 1, 2018 they will cover the new influenza virus vaccine code 90756 (Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, antibiotic free, 0.5mL dosage, for intramuscular use).

During the interim period of Aug. 1, 2017, through Dec. 31, 2017, Medicare Administrative Contractors (MACs) will use code Q2039 (Influenza virus vaccine, not otherwise specified) to handle bills for this new influenza virus vaccine product (Influenza virus vaccine, quadrivalent (ccIIV4). Q2039 is already an active code.

The new influenza virus vaccine code 90756 will then be implemented for DOS on or after Jan. 1, 2018.

  • Consult Codes not being paid

United Healthcare, has announced that they will stop paying for consult codes effective October 1, 2017.  This may be the wave of the future so make sure your billing service or office manager notifies you if other payers follow suit.

  • Documentation requirements for coding by time

Before you code by time make sure you know the documentation requirements.  The documentation must include the total time of the visit, a summary of the discussion or counseling AND support that over 50% of the visit was spent in counseling or coordination of care.

Three Ways to Increase Your Practice Collections

How much money is your practice losing?Increase Collections

Collections are the life-blood of your practice.  Yet, doctors in the United States lose roughly $125 billion per year due to poor billing practices.  According to an MGMA study, an average practice will recover just $15.77 for every $100 owed once a patient defaults on the amount they owe to you.

Below are some ways that can be implemented in order to maximize your collections. You will find that most are fairly easy and do not require additional resources.  They do require a concentrated effort but will prove to be financially beneficial.

PATIENT PORTAL

  1. Make sure you have a patient portal.
  2. Remember, having a patient portal isn’t enough.  You must maximize your patient portal.
  3. Make sure you have an online bill payment option.

PATIENT COLLECTIONS

  1. Give patients a wide variety of options for paying their bills.  Be sure to accept cash, checks, credit cards and debit cards.
  2. Encourage patients to register a credit card to keep on file with your office and make sure they enroll in an automatic pay option for their patient balances.
  3. Encourage patients to pay past account balances and current charges at the time of service.
  4. Train all staff to firmly but gently communicate with patients about patient financial responsibility issues.
  5. Be willing to refuse service to patients who do not pay.

OUTSOURCE YOUR MEDICAL BILLING

  1. When you transition to a billing company, you get trained specialists dedicated to medical billing.
  2. Outsourcing means you don’t have to worry about personnel issues, covering vacations or ongoing training expenses.
  3. Utilizing a billing company will afford you the benefits of state-of-the-art software, up-to-date processes and key reports in a timely fashion.
  4. Dedicated efforts, working every denial, and not accepting zero payments will result in your practice getting more money faster.

Maybe all three ways won’t work for your practice or maybe you’ve already done some and that is great.  Every way that you implement will only help to increase your practice collections.

Is Mod 59 a Magic Bullet?

Coding

Mod 59 codingWe’ve noticed an increase in the usage of modifier 59 (mod 59).  Oh we all want a magic bullet.  The code that will get every charge reimbursed the first time.   Although modifier 59 may get the claims paid it might not be the correct usage of the code.  After all there are no magic bullets.

Mod 59 does have a purpose. We asked a certified professional coder to explain when it should and shouldn’t be used.  Here is an explanation that you may find helpful.

Mod 59 is used on services that are commonly bundled and/or are not normally reported together. However, there are certain circumstances can be reported and paid separately.

WHEN SHOULD I USE MOD 59?

Adding mod 59 indicates that a procedure or service is distinct or independent from other non-E/M services performed on the same day.  You can use modifier 59 when

  1. the procedure is performed in a different session or patient encounter;
  2. there is a different procedure or surgery;
  3. there is a different site or organ system; or
  4. a separate incision/excision and separate lesions or separate injuries not ordinarily encountered or performed on the same day by the same individual.

For billing, bill all services performed in one day on the same claim.  Add mod 59 to the subsequent procedure if the other procedures are not normally reported together and is appropriate for the clinical circumstances.

NO ON MODIFIER 59

If a service is typically included in the performance of the primary procedure then the procedure is bundled and should not be reported with mod 59.  Modifier 59 should never be used when another more appropriate modifier exists to clarify the services performed and when the documentation does not support the separate and distinct status.

The Medicare National Correct Coding Initiative (NCCI) has also addressed the use of mod 59.  One function of NCCI PTP edits is to prevent payment for codes that report overlapping services except in those instances where the services are “separate and distinct.” Modifier 59 is an important NCCI-associated modifier that is often used incorrectly.  For more detailed information, click here for a copy of the related mod 59 article from the NCCI.

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