Billing Expert Offers Tips for Avoiding Fraud Charges
by Michael Vlessides
San Diego—Few physicians ever seriously consider the possibility of becoming formally acquainted with the Office of Inspector General or the FBI.
Yet according to Stanley W. Stead, MD, MBA, chief executive officer of the Los Angeles-based Stead Health Group, Inc., the line that separates legal from illegal billing practices sometimes can be a fine one, and one that every surgeon has a responsibility to understand.
In a presentation at the 2010 annual meeting of the American Society of Anesthesiologists (ASA), Dr. Stead discussed the latest developments in billing requirements, and the consequences that often arise when physicians stray beyond these bounds.
“Most physicians don’t understand what happens when you submit a bill, what laws apply, what penalties can be incurred,” said Dr. Stead, who chairs the ASA Committee on Economics. “A lot of people don’t think the orange suit is possible for them. But let me assure you, it very much is.”
Federal and state governments are more interested than ever in catching fraud. Officials often rely on whistle-blowers to expose such activity. The Department of Health and Human Services Office of Inspector General has found that the majority of such qui tam investigations are triggered by phone calls from disgruntled or former employees who take issue with the practice’s billing patterns.
Recovery audit contractors now use computer programs to systematically evaluate billing patterns. “Be aware that this is a situation where you’re very vulnerable, and you have to be absolutely faithful in the way you document and code,” Dr. Stead said.
Know the Code
Of the many ways that surgeons can run afoul of current legislation, coding issues are the most common, Dr. Stead said. “Creative coding” occurs when a billing code does not exist for a certain procedure, and the practitioner chooses a similar code or one with comparable value. “Unbundling” is the term for when a surgeon deconstructs a complex procedure (for which there is one code) and bills each part separately under different, individual codes. “Upcoding,” on the other hand, occurs when practitioners exaggerate their level of involvement.
“A good example is patient visits, when you say you did an E&M level 5 visit and you actually did a level 2,” Dr. Stead explained.
Surgeons also must strive to avoid using improper modifiers. Mistakes frequently occur when physicians do not understand the meaning of certain modifiers, yet include them in their billing anyway.
“If you don’t understand what a modifier is, you actually have to sit down and read about it in the CPT [Current Procedural Terminology] book,” Dr. Stead said.
Although unintentional documentation issues can strike the most well-intentioned practice, medically unbelievable edits are more considered. These typically involve multiple procedures provided on the same day. “Combinations of procedures are also problematic,” he continued. “Frankly, it’s difficult to believe a person would have a mastectomy and an orchiectomy on the same day. But people have tried to bill for this.”
Evaluation and management coding is another troublesome area for surgeons. “People are also getting into trouble right now over the use of templates in electronic medical records [EMRs],” Dr. Stead noted. “If you have comprehensive templates and you think you can justify a level 4 or 5 visit simply because you have a template in your EMR, chances are that money is going to have to be returned, plus a fine.”
Improper claims by nurse practitioners (NPs) and physician assistants (PAs)—who require their own distinct identification numbers—also can lead to investigation. All claims for services rendered to Medicare beneficiaries must be filed by the employer on behalf of the NP or PA. “You can never have your NP or PA bill in your name when you’re not physically in the office,” Dr. Stead explained.
Use Protection
So what does a surgeon need to do to help avoid these pitfalls? “Get good billing staff, and remember that they need the best documentation you can provide them,” Dr. Stead advised. “Billing slips and super bills are a poor substitute for good medical records. If your billing staff is billing from a super bill and not looking at your patient medical record, you are facing the possibility of grave consequences if they are inconsistent.”
Get a new CPT book every year and review it; codes change. Know the rules and follow them. Each payer is different. The physician, not the billing staff, ultimately is held accountable. “And if all else fails,” he added, “get good legal counsel.”
Douglas G. Merrill, MD, director of perioperative services at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., said that physicians who do not take the time to learn billing rules are putting themselves at risk.
“As far as the government is concerned, if you bill for medical care, you are expected to understand and follow the rules of billing for medical care,” Dr. Merrill said. “We can decry that none of us went to medical school to learn how to bill, but the fraud committed by the very few has forced this onerous requirement on all of us. We cannot ignore it.”
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