Little Mistakes Create Big Risk
By: GAIL F. BRANDT
Summer 1995
While the $161 million Caremark, Inc. agreed to pay to settle charges of paying kickbacks to physicians submitting false bills to Medicare and Medicaid has made headlines, it may have been a bargain. By agreeing to the settlement, Caremark avoided a mandatory five-year exclusion from Medicare and Medicaid.
A $30.00 Mistake
Other providers have not been so lucky. One physician was recently excluded for five years for accepting a single $30.00 "kickback" from the manufacturer of breathing equipment. The financial impact of his exclusion will be far more economically devastating to him than the settlement will be for Caremark. In another case, an oncologist was permanently excluded for providing services that were "in excess of patient needs" for seven patients. From the case notes, it appears that his medical records were fairly sloppy, and he also may not have been contrite when dealing with the regulators, who concluded that his choice of treatment was tainted by his desire to maximize Medicare and Medicaid reimbursement.
Risk Prevention
Health care providers can prevent problems with Medicare and Medicaid by developing a compliance program and periodically reviewing bill and coding practices. A compliance program can not only help catch mistakes early, but can also show your intent to comply with the law. This could be very important in preventing a mistake and possible overpayment from turning into a criminal or civil charge of fraud.
Develop a Billing Compliance Program
Establish an evaluation process that includes an initial review of actual practices, a plan for correcting any concerns identified in the review, and a periodic follow-up of billing practices.
Establish clear policies for employees who perform billing and claims processing functions. It is very important that they understand the consequences of coding mistakes and the limits on their authority to change codes.
Keep written notes on telephone calls regarding billing and coding practices with any agency or carrier. Whenever possible, document their advice in a follow-up letter.
Monitor contacts with agencies and carriers so you can identify any trends or note changes in the tone of correspondence.
Include commercial third-party payors in your review. They have a private right of action and frequently cooperate with government investigators.
Maintain Good Medical Records
The maintenance of good, complete medical records is not only important for the defense of a malpractice action, but also for showing that you billed for services that were both performed and medically appropriate. If it's not written in the patient's chart, it did not happen. documentation in the medical record must be consistent with coding and descriptions used on claim forms.
Respond to Carrier Notices
It is very important to take seriously all correspondence and inquiries from carriers and agencies. While some matters may be handled as routine, an increasing number of issues are being considered fraud or false billing. If you receive a letter from a carrier or agency that includes a request for repayment or identifies a mistake in coding, contact your health care attorney. This is important even if the amount in question is small. As the physicians in the cases discussed above learned, little mistakes can be very costly.