Now that school is in session, it’s time for a pop quiz. The topic: Medicare billing fraud.
Q: With which of the following statements do you agree?
a) I’m safe, because I’ve never intentionally committed fraud.
b) Mistakes made by the billing department are their problem, not mine.
c) A fraud investigation is only costly if you’re found guilty.
If you agreed with any of these statements, you may need to repeat the course on billing compliance—preferably before you code another file or sign another claim form.
YOUR NUMBER, YOUR RESPONSIBILITY
The federal government has made no secret of its aggressive pursuit of scammers who defraud Medicare at great cost to the public. The departments of Justice and of Health and Human Services have formed a Health Care Fraud Prevention and Enforcement Action Team (known as HEAT) with the goal of eliminating fraud and investigating Medicare and Medicaid operators who are cheating the system.
How big is the problem? It’s difficult to say, but estimates have placed the annual cost of Medicare fraud at anywhere from $50 billion to nearly double that amount. The lower figure comes from a Government Accountability Office report that estimated $48 billion in “improper payments” during fiscal year 2010 (in other words, nearly 10% of Medicare’s outlay that year). The higher estimate—up to $90 billion—has been cited by Attorney General Eric Holder, among others.
While a number of high-profile cases have been reported in the media—instances of fraud that have cost hundreds of millions of dollars each—there is speculation that a lot of the fraudulent activity that occurs within the health care system is actually the result of innocent or ignorant mistakes on the part of providers.
“Clearly, those people who are brought up on charges because they’ve billed for patients who didn’t come to the office, or they billed for procedures they haven’t done, are in a different category,” says Michael Powe, Vice President for Reimbursement and Professional Advocacy of the American Academy of Physician Assistants. “But in most other instances, we think it really is just a lack of understanding—either at the billing cycle point, where claims get submitted, or somewhere else down the line.”
Given the variety of payment structures and requirements across the board—from Medicare and other government programs to any of the large number of private payers—it would be hard not to be confused. “They can all have slightly different sets of rules that govern how PAs and NPs and other health care professionals are covered under their system,” Powe acknowledges. “Trying to keep track of those different regulations across programs can be a challenge.”
But it’s a challenge health care providers accept when they sign up with an insurer and acquire a provider number. “It doesn’t matter who is doing your billing: It’s your number,” says Barbara C. Phillips, MN, NP, who in addition to her clinical practice provides business coaching and consulting services to NPs. “You are still responsible for what gets billed out under your name and how charts get coded.”
Health care attorney Carolyn Buppert, MSN, JD, ANP, notes that the federal government “recently alerted clinicians—particularly physicians, but I think the principles apply to NPs and PAs as well—that they have responsibility for understanding how their provider number is being used.” Furthermore, “when you sign up for a Medicare provider number, you sign a little attestation clause at the bottom that says, essentially, ‘I will keep up with the changes and I will keep abreast of the rules.’”
Whether the billing service is in the same office, down the street, or across town, it doesn’t matter that the individual clinician may not have total control over the final submission. Everyone knows where the proverbial buck is going to stop.
HOW TO AVOID MISTAKES
Violating Medicare’s regulations can be a result of inexperience, such as coding every visit as a 99213. (Even experts who today present or consult on billing and coding topics admit there was a time when they “didn’t know any better,” either.) Another common mistake entails the preoperative history and physical; Medicare includes this service in its surgical global bundle, but some practices may try to bill for it separately. And of course, incident-to billing is a perennial pitfall for practices that employ NPs and PAs.
“Some practices don’t realize that the physician needs to be on site when a PA delivers care,” Powe says. “Even though that physician does not have to physically see or treat the patient, there must be a doc on site.”