3 Things To Do To Guarantee Healthcare Fraud

Funky Fraud Saturday Word Picture

To commit healthcare fraud you should 1) set your billing system to only bill the highest level codes; 2) have more billings than your closest competitor; 3) tell everyone about it.  These 3 things will guarantee the feds will come knocking on your door.  Sounds unbelievable? Unfortunately, it happens everyday.

Recently, the CEO and a physician of Chicago based, Mobile Doctors, a 6 state group of doctors that make house calls, were arrested for fraudulently billing Medicare millions of dollars.

“A former manager of the Chicago office told investigators that [the company] set up a system so that the two highest fee codes allowed by Medicare automatically kicked in so that patient visits would be worth the doctors’ time and the cost of gas, according to prosecutors….the manager quoted [the CEO] as telling his physicians, “I don’t pay for the ones or twos,” a reference to the lower fee codes. From 2006 to 2012, Mobile Doctors received more than $34 million in payments on claims using the two higher codes, according to the charges.

The charges also alleged that Mobile Doctors’ physicians falsely certified that patients they visited were confined to their homes, enabling home health care agencies to claim fees for additional services for patients who were not actually qualified to receive them.   Some 16,000 patients had been certified as homebound by the company since 2006, leading to more than 83,000 home health visits, many of them fraudulent, according to prosecutors. [The doctor who was arrested] accounted for more than 6,000 of the certifications and allegedly billed Medicare for about 17,500 patient visits he made, more than any other Mobile Doctors physician, prosecutors said.”

Chicago Tribune, August 28, 2013

Doctors often read these headlines and think “this can’t ever happen to me.”  However, it is actually quite easy to run afoul of the rules.  Ask yourself:  Have you ever been too busy to check the patient’s current status before you authorize home healthcare services?  Certifying patients who don’t qualify can be fraud.

A healthcare practitioner should performed external and internal audits of the billing system especially if it’s connected through your electronic medical record (EMR).  Be certain the system is set up so all level codes are available to the doctor.  If the doctor can’t bill the lower level codes, the feds might allege fraud.

Also, you should look at the comparable data for other doctors in your specialty in your area.  If you are billing more than other doctor in your specialty, you should ask “why.”  Many doctors just assume they treat sicker or more complex patients.  This isn’t always a reasonable defense.   The government targets doctors who are outliers as they often believe they are committing fraud.

Your compliance plan should be at work in your practice everyday checking for areas of potential fraud.  We know that: “Ignorance of the law is no excuse.”

Let us know how you are auditing your practice for potential areas of fraud.  We’d love to hear your experiences.

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