Career Code Red: Unintentional Medicare Billing Fraud

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.”

That stipulation assumes that a professional service was provided by the physician on the patient’s initial visit for that particular medical problem, otherwise the incident-to provision cannot be implemented on a subsequent visit. As Phillips points out, the incident-to billing rule “is certainly not nebulous, but it is confusing to people.”

Consider the case of a regular patient who presents for follow-up on his/her diabetes. “How often do you hear, ‘Oh, by the way…’ and it’s a whole new issue? That just blows incident-to out of the water. There isn’t a patient who sticks to any script. They don’t read the rules,” Phillips says with a laugh.

Technology may, in some ways, exacerbate billing and coding issues that can provoke suspicion on the part of Medicare authorities. Electronic medical records (EMRs) have introduced cloning into a clinician’s documentation process—and that’s not always a good thing.

“People are just reusing the same note over and over, and they’re not necessarily catching the changes, so it looks like a recycled note,” Phillips says. “If I don’t make sure to go in and update every single area, it may look like the same note. If [the patient encounter] is the same, it’s the same, but you’ve really got to watch what you’re documenting and make sure you are following the guidelines.”

Powe also cautions against allowing the cut-and-paste mentality to distract a clinician from doing proper documentation. He adds, “Some of the EMR systems will also prompt health care professionals ‘Did you do this? Did you do that?’ with the idea of trying to attain a higher level of code. That’s fine—as long as what you put on the record that you did really meets the test of medical necessity.”

“Make sure you are actually doing the work,” Phillips advises. “And don’t go looking for things that aren’t necessarily there, just to fill in the chart.”

Accurate and adequate documentation is part of Health Care 101, but not all education programs provide extensive training in billing and coding. While NPs and PAs may need to seek this expertise on their own, the opportunities are plentiful. The syllabus for nearly every professional conference usually includes at least one or two courses in coding. There are also a variety of online resources and Webinars that clinicians can review at their leisure; Phillips recommends the free video course offered by EMUniversity

.com. Buppert has developed training modules that are available for purchase by individuals or institutions, but also notes that local Medicare administrative contractors often conduct teleconferences and “lunch and learn” sessions.

“You can get the training,” she says. “It does take time, but the access is there.”

THE COST IS HIGH
Clinicians have to decide what is more important: finding time to bring themselves up to speed or paying the consequences of a potential investigation by Medicare (or another authority) if any violations occur. Even if an intention to commit fraud is not found, the costs to a health care provider and his/her practice can be substantial.

“I would suggest that Medicare does understand an honest mistake, and when those are made, they typically take back the reimbursement and call it a day,” Powe says. “Now, it’s also possible that if Medicare sees a long-term pattern of inappropriate or mistaken billing, that could very well trigger a practice audit.”

At that point, Phillips says, “the burden of having to prove what you did or did not do becomes incumbent on you. Often, you’re going to need to get an attorney, particularly one who is familiar with health care and audits and this whole issue of the Recovery Act.”

Buppert has been contacted by clinicians who have been audited and subsequently required to pay back sums ranging from $25,000 to $80,000. Typically, 5% to 10% of charts are reviewed, with findings extrapolated to the clinician’s or the practice’s total billing. For example, if medical necessity is not adequately documented on 50% of the audited charts, the fine is assessed to half of the submitted bills. If the auditors find a problem with 100% of the charts reviewed, they can deny payment for all submitted bills.

Buppert recently had a client who was going to be denied payment for 100% of her bills, due to what the auditors determined was poor documentation of the necessity for home visits. The clinician was ultimately cleared of wrongdoing, but not until she’d consulted two attorneys and had her case presented before administrative law judges. “It was an honest mistake, and it was resolved,” Buppert says, “but she had a large legal bill, so it was not a tremendously good result.”

To avoid the costs in time, stress, and legal bills (not to mention massive fines and possible jail time in egregious cases), Buppert emphasizes, “If you’re doing billing—especially if you’re in your own business, but even if you’re not—you need to know the requirements of Medicare, especially for documenting what you’ve done in order to justify the bill.”

For NPs and PAs, there may be an additional area of concern, depending on the state, the practice agreement, and their relationship with their supervising/collaborating physician. If they see billing practices in place that confuse them or make them uncomfortable, what can they do?

“Try to approach it in a way that’s a win-win for everybody,” Phillips suggests. “You’re not trying to accuse anybody or anything like that; you just want to make sure that everything is aboveboard, for everyone’s sake. You know, ‘I’ve been reading about issues with fraud and all these audits and how people are billing incident-to, and I just want to get a clear idea of how we’re doing that, so that we’re all staying out of trouble.’”

“If you know something is being done illegally, inappropriately, or fraudulently, there’s really not much question about what the appropriate response is,” Powe says. “However, what’s really important is, if there is some concern or question, at that point I think it should be raised with the supervising physician and there should be a checking of the rules and regulations.”

If the subject is broached with the intention of protecting the practice as well as the individual clinicians, there should be no objection to clarifying or reviewing billing procedures. “If protecting the practice is the basis upon which the question is asked,” Powe says, “we hope that will elicit the proper response from the supervising physician, who should also want to make sure that there are no inappropriate things occurring within the practice.”

And should the practice be engaging in illegal activities, make no mistake: There is an expectation that anyone with knowledge of fraudulent billing practices will report them through the Office of the Inspector General. “The government is leaning more toward ‘If you know there’s a problem, you can’t just sit by and let it go,’” Buppert says, although she cautions that clinicians should first try to address the issue internally and be sure their data is 100% solid before they turn in an employer.

Most NPs and PAs simply want to provide excellent patient care and be compensated for their services; they don’t want to police their clinical settings. But mistakes can be costly, and innocent errors are likely to increase when the threat of ICD-10 finally becomes reality. An ounce of prevention really can be worth a pound of cure—and sometimes, it can be what saves a career.

“Clinicians have to understand that their ability to maintain their license and practice clinically could be placed in jeopardy if there is an inappropriate use of billing mechanisms,” Powe says. “If fraud and abuse charges are brought upon them, that could eliminate their ability to practice.”

“All of us have an obligation, whether we are employed by somebody else, in government service, or self-employed, to understand the business of health care and understand these rules about getting paid,” Phillips concludes. “We have to get educated, because I think the rules are only going to become more complicated.”

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.”

That stipulation assumes that a professional service was provided by the physician on the patient’s initial visit for that particular medical problem, otherwise the incident-to provision cannot be implemented on a subsequent visit. As Phillips points out, the incident-to billing rule “is certainly not nebulous, but it is confusing to people.”

Consider the case of a regular patient who presents for follow-up on his/her diabetes. “How often do you hear, ‘Oh, by the way…’ and it’s a whole new issue? That just blows incident-to out of the water. There isn’t a patient who sticks to any script. They don’t read the rules,” Phillips says with a laugh.

Technology may, in some ways, exacerbate billing and coding issues that can provoke suspicion on the part of Medicare authorities. Electronic medical records (EMRs) have introduced cloning into a clinician’s documentation process—and that’s not always a good thing.

“People are just reusing the same note over and over, and they’re not necessarily catching the changes, so it looks like a recycled note,” Phillips says. “If I don’t make sure to go in and update every single area, it may look like the same note. If [the patient encounter] is the same, it’s the same, but you’ve really got to watch what you’re documenting and make sure you are following the guidelines.”

Powe also cautions against allowing the cut-and-paste mentality to distract a clinician from doing proper documentation. He adds, “Some of the EMR systems will also prompt health care professionals ‘Did you do this? Did you do that?’ with the idea of trying to attain a higher level of code. That’s fine—as long as what you put on the record that you did really meets the test of medical necessity.”

“Make sure you are actually doing the work,” Phillips advises. “And don’t go looking for things that aren’t necessarily there, just to fill in the chart.”

Accurate and adequate documentation is part of Health Care 101, but not all education programs provide extensive training in billing and coding. While NPs and PAs may need to seek this expertise on their own, the opportunities are plentiful. The syllabus for nearly every professional conference usually includes at least one or two courses in coding. There are also a variety of online resources and Webinars that clinicians can review at their leisure; Phillips recommends the free video course offered by EMUniversity

.com. Buppert has developed training modules that are available for purchase by individuals or institutions, but also notes that local Medicare administrative contractors often conduct teleconferences and “lunch and learn” sessions.

“You can get the training,” she says. “It does take time, but the access is there.”

THE COST IS HIGH
Clinicians have to decide what is more important: finding time to bring themselves up to speed or paying the consequences of a potential investigation by Medicare (or another authority) if any violations occur. Even if an intention to commit fraud is not found, the costs to a health care provider and his/her practice can be substantial.

“I would suggest that Medicare does understand an honest mistake, and when those are made, they typically take back the reimbursement and call it a day,” Powe says. “Now, it’s also possible that if Medicare sees a long-term pattern of inappropriate or mistaken billing, that could very well trigger a practice audit.”

At that point, Phillips says, “the burden of having to prove what you did or did not do becomes incumbent on you. Often, you’re going to need to get an attorney, particularly one who is familiar with health care and audits and this whole issue of the Recovery Act.”

Buppert has been contacted by clinicians who have been audited and subsequently required to pay back sums ranging from $25,000 to $80,000. Typically, 5% to 10% of charts are reviewed, with findings extrapolated to the clinician’s or the practice’s total billing. For example, if medical necessity is not adequately documented on 50% of the audited charts, the fine is assessed to half of the submitted bills. If the auditors find a problem with 100% of the charts reviewed, they can deny payment for all submitted bills.

Buppert recently had a client who was going to be denied payment for 100% of her bills, due to what the auditors determined was poor documentation of the necessity for home visits. The clinician was ultimately cleared of wrongdoing, but not until she’d consulted two attorneys and had her case presented before administrative law judges. “It was an honest mistake, and it was resolved,” Buppert says, “but she had a large legal bill, so it was not a tremendously good result.”

To avoid the costs in time, stress, and legal bills (not to mention massive fines and possible jail time in egregious cases), Buppert emphasizes, “If you’re doing billing—especially if you’re in your own business, but even if you’re not—you need to know the requirements of Medicare, especially for documenting what you’ve done in order to justify the bill.”

For NPs and PAs, there may be an additional area of concern, depending on the state, the practice agreement, and their relationship with their supervising/collaborating physician. If they see billing practices in place that confuse them or make them uncomfortable, what can they do?

“Try to approach it in a way that’s a win-win for everybody,” Phillips suggests. “You’re not trying to accuse anybody or anything like that; you just want to make sure that everything is aboveboard, for everyone’s sake. You know, ‘I’ve been reading about issues with fraud and all these audits and how people are billing incident-to, and I just want to get a clear idea of how we’re doing that, so that we’re all staying out of trouble.’”

“If you know something is being done illegally, inappropriately, or fraudulently, there’s really not much question about what the appropriate response is,” Powe says. “However, what’s really important is, if there is some concern or question, at that point I think it should be raised with the supervising physician and there should be a checking of the rules and regulations.”

If the subject is broached with the intention of protecting the practice as well as the individual clinicians, there should be no objection to clarifying or reviewing billing procedures. “If protecting the practice is the basis upon which the question is asked,” Powe says, “we hope that will elicit the proper response from the supervising physician, who should also want to make sure that there are no inappropriate things occurring within the practice.”

And should the practice be engaging in illegal activities, make no mistake: There is an expectation that anyone with knowledge of fraudulent billing practices will report them through the Office of the Inspector General. “The government is leaning more toward ‘If you know there’s a problem, you can’t just sit by and let it go,’” Buppert says, although she cautions that clinicians should first try to address the issue internally and be sure their data is 100% solid before they turn in an employer.

Most NPs and PAs simply want to provide excellent patient care and be compensated for their services; they don’t want to police their clinical settings. But mistakes can be costly, and innocent errors are likely to increase when the threat of ICD-10 finally becomes reality. An ounce of prevention really can be worth a pound of cure—and sometimes, it can be what saves a career.

“Clinicians have to understand that their ability to maintain their license and practice clinically could be placed in jeopardy if there is an inappropriate use of billing mechanisms,” Powe says. “If fraud and abuse charges are brought upon them, that could eliminate their ability to practice.”

“All of us have an obligation, whether we are employed by somebody else, in government service, or self-employed, to understand the business of health care and understand these rules about getting paid,” Phillips concludes. “We have to get educated, because I think the rules are only going to become more complicated.”

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.”

That stipulation assumes that a professional service was provided by the physician on the patient’s initial visit for that particular medical problem, otherwise the incident-to provision cannot be implemented on a subsequent visit. As Phillips points out, the incident-to billing rule “is certainly not nebulous, but it is confusing to people.”

Consider the case of a regular patient who presents for follow-up on his/her diabetes. “How often do you hear, ‘Oh, by the way…’ and it’s a whole new issue? That just blows incident-to out of the water. There isn’t a patient who sticks to any script. They don’t read the rules,” Phillips says with a laugh.

Technology may, in some ways, exacerbate billing and coding issues that can provoke suspicion on the part of Medicare authorities. Electronic medical records (EMRs) have introduced cloning into a clinician’s documentation process—and that’s not always a good thing.

“People are just reusing the same note over and over, and they’re not necessarily catching the changes, so it looks like a recycled note,” Phillips says. “If I don’t make sure to go in and update every single area, it may look like the same note. If [the patient encounter] is the same, it’s the same, but you’ve really got to watch what you’re documenting and make sure you are following the guidelines.”

Powe also cautions against allowing the cut-and-paste mentality to distract a clinician from doing proper documentation. He adds, “Some of the EMR systems will also prompt health care professionals ‘Did you do this? Did you do that?’ with the idea of trying to attain a higher level of code. That’s fine—as long as what you put on the record that you did really meets the test of medical necessity.”

“Make sure you are actually doing the work,” Phillips advises. “And don’t go looking for things that aren’t necessarily there, just to fill in the chart.”

Accurate and adequate documentation is part of Health Care 101, but not all education programs provide extensive training in billing and coding. While NPs and PAs may need to seek this expertise on their own, the opportunities are plentiful. The syllabus for nearly every professional conference usually includes at least one or two courses in coding. There are also a variety of online resources and Webinars that clinicians can review at their leisure; Phillips recommends the free video course offered by EMUniversity

.com. Buppert has developed training modules that are available for purchase by individuals or institutions, but also notes that local Medicare administrative contractors often conduct teleconferences and “lunch and learn” sessions.

“You can get the training,” she says. “It does take time, but the access is there.”

THE COST IS HIGH
Clinicians have to decide what is more important: finding time to bring themselves up to speed or paying the consequences of a potential investigation by Medicare (or another authority) if any violations occur. Even if an intention to commit fraud is not found, the costs to a health care provider and his/her practice can be substantial.

“I would suggest that Medicare does understand an honest mistake, and when those are made, they typically take back the reimbursement and call it a day,” Powe says. “Now, it’s also possible that if Medicare sees a long-term pattern of inappropriate or mistaken billing, that could very well trigger a practice audit.”

At that point, Phillips says, “the burden of having to prove what you did or did not do becomes incumbent on you. Often, you’re going to need to get an attorney, particularly one who is familiar with health care and audits and this whole issue of the Recovery Act.”

Buppert has been contacted by clinicians who have been audited and subsequently required to pay back sums ranging from $25,000 to $80,000. Typically, 5% to 10% of charts are reviewed, with findings extrapolated to the clinician’s or the practice’s total billing. For example, if medical necessity is not adequately documented on 50% of the audited charts, the fine is assessed to half of the submitted bills. If the auditors find a problem with 100% of the charts reviewed, they can deny payment for all submitted bills.

Buppert recently had a client who was going to be denied payment for 100% of her bills, due to what the auditors determined was poor documentation of the necessity for home visits. The clinician was ultimately cleared of wrongdoing, but not until she’d consulted two attorneys and had her case presented before administrative law judges. “It was an honest mistake, and it was resolved,” Buppert says, “but she had a large legal bill, so it was not a tremendously good result.”

To avoid the costs in time, stress, and legal bills (not to mention massive fines and possible jail time in egregious cases), Buppert emphasizes, “If you’re doing billing—especially if you’re in your own business, but even if you’re not—you need to know the requirements of Medicare, especially for documenting what you’ve done in order to justify the bill.”

For NPs and PAs, there may be an additional area of concern, depending on the state, the practice agreement, and their relationship with their supervising/collaborating physician. If they see billing practices in place that confuse them or make them uncomfortable, what can they do?

“Try to approach it in a way that’s a win-win for everybody,” Phillips suggests. “You’re not trying to accuse anybody or anything like that; you just want to make sure that everything is aboveboard, for everyone’s sake. You know, ‘I’ve been reading about issues with fraud and all these audits and how people are billing incident-to, and I just want to get a clear idea of how we’re doing that, so that we’re all staying out of trouble.’”

“If you know something is being done illegally, inappropriately, or fraudulently, there’s really not much question about what the appropriate response is,” Powe says. “However, what’s really important is, if there is some concern or question, at that point I think it should be raised with the supervising physician and there should be a checking of the rules and regulations.”

If the subject is broached with the intention of protecting the practice as well as the individual clinicians, there should be no objection to clarifying or reviewing billing procedures. “If protecting the practice is the basis upon which the question is asked,” Powe says, “we hope that will elicit the proper response from the supervising physician, who should also want to make sure that there are no inappropriate things occurring within the practice.”

And should the practice be engaging in illegal activities, make no mistake: There is an expectation that anyone with knowledge of fraudulent billing practices will report them through the Office of the Inspector General. “The government is leaning more toward ‘If you know there’s a problem, you can’t just sit by and let it go,’” Buppert says, although she cautions that clinicians should first try to address the issue internally and be sure their data is 100% solid before they turn in an employer.

Most NPs and PAs simply want to provide excellent patient care and be compensated for their services; they don’t want to police their clinical settings. But mistakes can be costly, and innocent errors are likely to increase when the threat of ICD-10 finally becomes reality. An ounce of prevention really can be worth a pound of cure—and sometimes, it can be what saves a career.

“Clinicians have to understand that their ability to maintain their license and practice clinically could be placed in jeopardy if there is an inappropriate use of billing mechanisms,” Powe says. “If fraud and abuse charges are brought upon them, that could eliminate their ability to practice.”

“All of us have an obligation, whether we are employed by somebody else, in government service, or self-employed, to understand the business of health care and understand these rules about getting paid,” Phillips concludes. “We have to get educated, because I think the rules are only going to become more complicated.”