Tom Pliura, MD, JD, an independent attorney specializing in healthcare issues for surgery centers and physician practices and founder of zCHART and the zCHART EMR, discusses the increase in physician fraud investigations and offers suggestions as to how physicians and administrators can protect themselves from these investigations.
Q: There seems to be an increase in the number of physicians being investigated for Medicare and Medicaid fraud. Why do you think we are seeing these increases?Tom Pliura:
In my opinion, we are seeing these increases due to the federal government’s decision to make healthcare fraud a target area. We have seen an increased emphasis by the government cracking down on allegations of fraud for the last couple of years due to HHS including these investigations in its “scope of work.” The federal government can potentially save a lot of money by cracking down on Medicare fraud. The same goes for states and Medicaid fraud. As a result, I’m not surprised that we are seeing more physicians and healthcare providers being investigated for this than in the past. Specifically, HHS is paying careful attention to the services that cost the government a lot of money. The costs of certain services have risen dramatically over the past few years. Take rehabilitation for example. In the past 10 years, there has been a dramatic increase in these types of services. The government investigates and asks questions like “Are these services medically necessary?” or “Are these increases in services being provided not because they are medically necessary but instead merely to generate income?”
Q: What are the most common types of suspected fraud that you are seeing physicians investigated for?
TP: Billing for services not medically necessary and billing for services not rendered, intentionally or unintentionally, are some of the more common types of fraud being investigated. One big issue is the place of service. If a biller says a procedure was performed in the office when in fact it actually occurred in a hospital, this could be interpreted as fraud, even if the place of service code mistake was unintentional. The government uses a carrot-and-stick approach to encourage physicians to perform procedures in their offices because this saves Medicare on facility fees. As a result, Medicare provides a higher fee to the physician for some procedures performed in-office. Where a physician can get into trouble is if he or she does not properly document where the procedure is being done in the patient chart. When the biller receives the chart, she or he may just pick a place of service to avoid hassling the physician with questions. If the biller guesses wrong, you could be at risk for an investigation Another issue where fraud occurs is with unbundling certain services. Again, this may be intentional or unintentional. For example, a biller might unwittingly unbundle a particular service that should have been bundled together under one single CPT code. For example, let’s say a patient goes in for a colonoscopy and during the colonoscopy the physician decides to perform a hemorrhoid service. Because colonoscopies are bundled by Medicare, the facility should not bill separately for the hemorrhoid treatment. If for some reason this is unbundled, it could be viewed as healthcare fraud because it profits the facility. Finally, billing for follow-up office visits is also an area where we are seeing facilities getting into trouble. Many Medicare fees for medical incidents include a follow-up visit. If these are billed for separately, or an additional follow-up is requested by the physician, the government might look into these practices. For example, let’s say I go in for a wound infection after surgery and my doctor requests a follow-up in one week. The question becomes “is that additional follow-up appointment medically necessary?” The problem is it’s often a judgment call on the part of the physician in many ways. As a result, it’s important physicians document why each follow-up they request is medically necessary.
Q: What can physicians do to ensure that they are not inadvertently involved in fraud?
TP: You have to educate your staff about the importance of being accurate. Often, the physician or physician-owners don’t even see the billing process once the chart leaves the committing physician’s hands, but those physicians are ultimately responsible if improper billing occurs. Doctors have to take an active role in the billing procedures of their facility or they could inadvertently be involved in fraud. Physicians are great at keeping up-to-date in their clinical specialties but they are not so good at keeping up-to-date on billing and reimbursement rules, which are often very complex. One problem is that physician education deals only with clinical issues, yet many physicians own their own practices, surgery centers or other facilities. Most were never formally educated about how to bill or how to run a business office. Physicians need to involve employees who are familiar with the rules and who keep abreast of these regulations. Physicians need to understand this and work to ensure that their facilities are following up-to-date and proper procedures. They also need to document why each medical decision they make is medically necessary. If a physician can support their judgment calls, they are at much less risk for being found to have acted fraudulently, if an investigation occurs. I don’t think that the government wants to split hairs here. The government is focusing on issues and areas that have historically been at risk for fraudulent activity, and rightfully so. The government is comparing data on facilities and physicians and looking for outliers. If they find a facility or physician that has considerably more follow-ups, for example, than others, then they will start to take a careful look at the facility’s or physician’s records. The main thing is that physicians and centers need to get guidelines into place and follow them. I recommend that all facilities have a random audit system in place. You don’t have to audit every chart; 5 percent of cases would be fine. But, the audit has to be performed by someone outside your billing department. You don’t need to spend a lot of money on this, but simply showing that you have a procedure in place can protect you if an allegation of fraud is ever made against you or your facility. If you have these guidelines, and follow them and use common sense, any inconsistencies that investigators find can be easily supported. Your decisions, or your physicians’ decisions, are easily defensible because you have clearly documented medical reasons for those decisions.
Contact Mr. Pliura ( tom.pliura@zchart.com) at (309) 962-2299. Learn more about zCHART at www. zchart.com.
Q: There seems to be an increase in the number of physicians being investigated for Medicare and Medicaid fraud. Why do you think we are seeing these increases?Tom Pliura:
In my opinion, we are seeing these increases due to the federal government’s decision to make healthcare fraud a target area. We have seen an increased emphasis by the government cracking down on allegations of fraud for the last couple of years due to HHS including these investigations in its “scope of work.” The federal government can potentially save a lot of money by cracking down on Medicare fraud. The same goes for states and Medicaid fraud. As a result, I’m not surprised that we are seeing more physicians and healthcare providers being investigated for this than in the past. Specifically, HHS is paying careful attention to the services that cost the government a lot of money. The costs of certain services have risen dramatically over the past few years. Take rehabilitation for example. In the past 10 years, there has been a dramatic increase in these types of services. The government investigates and asks questions like “Are these services medically necessary?” or “Are these increases in services being provided not because they are medically necessary but instead merely to generate income?”
Q: What are the most common types of suspected fraud that you are seeing physicians investigated for?
TP: Billing for services not medically necessary and billing for services not rendered, intentionally or unintentionally, are some of the more common types of fraud being investigated. One big issue is the place of service. If a biller says a procedure was performed in the office when in fact it actually occurred in a hospital, this could be interpreted as fraud, even if the place of service code mistake was unintentional. The government uses a carrot-and-stick approach to encourage physicians to perform procedures in their offices because this saves Medicare on facility fees. As a result, Medicare provides a higher fee to the physician for some procedures performed in-office. Where a physician can get into trouble is if he or she does not properly document where the procedure is being done in the patient chart. When the biller receives the chart, she or he may just pick a place of service to avoid hassling the physician with questions. If the biller guesses wrong, you could be at risk for an investigation Another issue where fraud occurs is with unbundling certain services. Again, this may be intentional or unintentional. For example, a biller might unwittingly unbundle a particular service that should have been bundled together under one single CPT code. For example, let’s say a patient goes in for a colonoscopy and during the colonoscopy the physician decides to perform a hemorrhoid service. Because colonoscopies are bundled by Medicare, the facility should not bill separately for the hemorrhoid treatment. If for some reason this is unbundled, it could be viewed as healthcare fraud because it profits the facility. Finally, billing for follow-up office visits is also an area where we are seeing facilities getting into trouble. Many Medicare fees for medical incidents include a follow-up visit. If these are billed for separately, or an additional follow-up is requested by the physician, the government might look into these practices. For example, let’s say I go in for a wound infection after surgery and my doctor requests a follow-up in one week. The question becomes “is that additional follow-up appointment medically necessary?” The problem is it’s often a judgment call on the part of the physician in many ways. As a result, it’s important physicians document why each follow-up they request is medically necessary.
Q: What can physicians do to ensure that they are not inadvertently involved in fraud?
TP: You have to educate your staff about the importance of being accurate. Often, the physician or physician-owners don’t even see the billing process once the chart leaves the committing physician’s hands, but those physicians are ultimately responsible if improper billing occurs. Doctors have to take an active role in the billing procedures of their facility or they could inadvertently be involved in fraud. Physicians are great at keeping up-to-date in their clinical specialties but they are not so good at keeping up-to-date on billing and reimbursement rules, which are often very complex. One problem is that physician education deals only with clinical issues, yet many physicians own their own practices, surgery centers or other facilities. Most were never formally educated about how to bill or how to run a business office. Physicians need to involve employees who are familiar with the rules and who keep abreast of these regulations. Physicians need to understand this and work to ensure that their facilities are following up-to-date and proper procedures. They also need to document why each medical decision they make is medically necessary. If a physician can support their judgment calls, they are at much less risk for being found to have acted fraudulently, if an investigation occurs. I don’t think that the government wants to split hairs here. The government is focusing on issues and areas that have historically been at risk for fraudulent activity, and rightfully so. The government is comparing data on facilities and physicians and looking for outliers. If they find a facility or physician that has considerably more follow-ups, for example, than others, then they will start to take a careful look at the facility’s or physician’s records. The main thing is that physicians and centers need to get guidelines into place and follow them. I recommend that all facilities have a random audit system in place. You don’t have to audit every chart; 5 percent of cases would be fine. But, the audit has to be performed by someone outside your billing department. You don’t need to spend a lot of money on this, but simply showing that you have a procedure in place can protect you if an allegation of fraud is ever made against you or your facility. If you have these guidelines, and follow them and use common sense, any inconsistencies that investigators find can be easily supported. Your decisions, or your physicians’ decisions, are easily defensible because you have clearly documented medical reasons for those decisions.
Contact Mr. Pliura ( tom.pliura@zchart.com) at (309) 962-2299. Learn more about zCHART at www. zchart.com.