HomeAbout UsServicesResourcesClient Testimonials

What You Don't Know Can Hurt You
You’ve probably been reading more than you should about groups of doctors sending back money. Accusations of incorrect billings, fraudulent behavior, and false claims are common occurrences. Make it your New Year’s resolution to avoid all of this. You will have to be diligent, but I will provide you with information that will help you get started.  

The Office of Inspector General’s (OIG) Fiscal Year 2013 summarizes new and ongoing reviews as well as activities that the OIG plans to pursue with respect to Health and Human Services (HHS) programs during the next fiscal year (FY) and beyond. If you want to review their list of concerns I would highly encourage you to review the work plan located at https://oig.hhs.gov/reports-and-publications/archives/workplan/2013/Work-Plan-2013.pdf.  Familiarize yourself with what Medicare and Medicaid are looking for this year and you will see how critically important it is for you to be proactive.  

You can look at the work plan anytime and find out what they are reviewing, but I want to give you a taste of what the commercial plans are looking at these days. I believe most practices haven’t been that concerned with commercial payers and have focused on Medicare/Medicaid compliance. Generally, physicians haven’t felt threatened by commercial payers because they lacked infrastructure and staff to keep track of how claims are being billed. This has changed dramatically with many commercial payers. They are more active in this than ever before.  

An example of this change is demonstrated in a letter that a large commercial payer sent to a solo family physician. The subject of the letter stated CODING and it started out as follows:

ABC Insurance understands the importance of claims processing to practicing physicians. A key part of the service we provide is the facilitation of benefit payments in accordance with the terms and provisions of the member’s plan. Based on a review of claims data, we have identified concerns in your billing practices. Submitted claims and corresponding medical records have been reviewed and we would like to address the variances listed below.    

This particular doctor was then told he had a number of issues that needed correcting immediately. I want to share with you the three items in detail as well as recommendations for ensuring these things don’t happen to you. Being proactive is the key to compliance.  

First Issue
The first concern involves Physician Assistants and Nurse Practitioners (PA/NP). As you know, in primary care these physician extenders are a popular choice to employ. I’ve been asked by numerous practices to assist with hiring these individuals. They are less expensive than bringing on another physician and their extensive services can be managed and supervised pretty easily. There are requirements in regards to supervision and oversight of medical records, but these individuals can be a great asset. Of course with great assets comes greater scrutiny. The thing to keep in mind is that Medicare may do things one way, but many commercial plans can follow different rules.  

As a refresher, Medicare has rules for billing PAs/NPs. Medicare allows physicians to file extenders under their provider number for established patients. These claims are “incident to” the physician when the supervising physician is in the office suite and immediately available to the extender during the visit. If this occurs, the claim can be billed under the physician’s provider number and payment is based on the doctors Medicare allowable fee. However, if the physician is not on the premises and therefore not “incident to”, the extender must file under their name and provider number. A 15% reduction is applied to the service when this situation occurs.  

The commercial payer in this example would handle the claim very differently. It would be reasonable to assume that “incident to” rules would apply. However, in this example that is not the case. The first issue stated:

Billing for medical services performed by the Physician Assistant/Nurse Practitioner (Physician Extenders) under Dr. _____’s name instead of under the actual servicing provider. The contract outlines that there is a different percentage of reimbursement when services are performed by the assistant. The claims should be billed under the correct servicing provider’s name.  

In other words the payer does not recognize “incident to”. This means if the extender provided the service there is a reduction in payment regardless of whether the doctor is on the premises or not. This is becoming more of a rule than an exception. Payers are implementing reductions in payment when any extender provides the service.  

Medicare has always been a standard and bench mark in the industry. However, in this case the commercial plan is more restrictive when it comes to extender reimbursement.  

The moral of this story is to check all of your contracts to ensure you are billing extender services appropriately. The physician in the example unfortunately found out the hard way with refunds and scrutiny for false claims. Don’t let this happen to you.  

Second Issue
The second issue involves pass through billing for services that generally require equipment to perform and subsequent interpretation. It includes billing services globally and having the entity that owns the equipment or does the interpretation then bill the practice for services. You see this when lab is drawn from the practice, the specimen is sent to the lab for testing, and the results are sent back to the doctor. The doctor bills globally for the test as if he provided the service and then the lab bills the doctor. Depending on the arrangement this might be permissible.  

In other cases, the arrangement could be similar to the doctor in this case who is being questioned. The statement was defined in the letter from the payer as follows:

The global aspect of testing is billed by your office when the services are done by another provider or entity. Another provider is bringing the equipment into your office, performing the testing and it is sent out for interpretation. The provider who owns the equipment should be billing for the technical component of the testing and the provider who does the interpretation should bill the interpretation.  

In other words, these companies are providing testing in the office and the physician is billing globally for services the company performs. Although some payers may allow this procedure, many payers are informing providers not to bill for services that they did not provide themselves.  

The moral of this story is to have these arrangements reviewed by a healthcare attorney who has experience in these matters and get results in writing. This will protect you from payers that may frown on these situations and suggest the practice is billing false claims.  

Third Issue
The third and final issue involves commercial payers increasing scrutiny on evaluation and management codes. It is not unusual for payers to review levels of service to ensure medical record documentation meets the requirements for the code billed. The tenacity of payers has become more substantial as they see the opportunity of recovering revenue. The statement in the letter was:

Medical records lacked documentation and/or appropriate documentation to support services.

Higher level office visits are being reviewed more consistently and comparisons to peer groups are becoming more standard operating procedure. The documentation has to back up any code billed or refunds are being requested. Don’t find yourself in this situation.  

So, how much do you know about evaluation and management codes? Here is a test to measure your knowledge. Answers are at the bottom.  

1.What are the 4 key elements that make up the evaluation and management coding system?

2.How many elements must be documented in the “ROS” review of systems for this subcomponent of the 
    History element to be considered “complete”?

3.Which E&M element establishes the medical necessity of any type of visit?

4.How many elements must be documented for an extended history of the present illness (HPI)?

5.When is a patient considered a new patient to a physician?

If you didn’t know the answer to these questions, you need to have your records reviewed independently to determine any deficiencies and potential improvements necessary for compliance. Ensuring your documentation meets all requirements for the codes billed is more critical than ever and will continue to challenge physicians into the future.  

1.Chief complaint, history, exam, medical decision making
3.Chief complaint
5.When a patient has not been seen in over three years or someone of the same specialty in the same group over three years.