Recently, I have been dismayed to learn that some of our PA and NP colleagues have been caught up in serious federal fraudulent-billing cases. There is, of course, no precise measure of health care fraud, nor is there any doubt that the majority of PAs and NPs are honest and well intentioned.
In 1997, Congress authorized payments to NPs and PAs for Medicare-provided services; the attendant rules and regulations have become more complex over time, creating a new area of liability for both professions. Failure to follow billing rules typically results in payment denial and/or repayment of fees already paid.
However, in cases deemed egregious, the penalties can include criminal prosecution, punitive damages, and exclusion from participation in federally funded health care programs. Should you be excluded, for all practical purposes your medical career is over. Medicare forbids hospitals and health plans to employ excluded persons or contract with organizations that employ them.
Here are a couple of recent examples from the public record:
A multistate urgent care company was sued by the US Department of Justice (DoJ) and five states for implementing unethical corporate-wide initiatives aimed at generating additional income. The scheme included setting quotas for the performance of medically questionable—and often unnecessary—testing for allergy problems, regardless of the presenting condition. In addition, clinicians were required to “hard sell” immunotherapy drops not approved by the FDA, which in most cases were not effective.
This company employed many PAs and NPs, who were required to meet daily quotas or risk being fired, in order to offset the company’s struggling finances. The suit with the DoJ was settled in the multimillion-dollar range; however, the company and its principals are still at risk for lawsuits from private individuals and private health plans that were defrauded.
This significant settlement highlights the danger of putting greed before ethics and good patient care. Clinicians work very hard to attain their clinical license and should not let others put their career goals at risk.
In another case, a PA was convicted on multiple criminal counts of conspiracy, health care fraud, and aggravated identity theft in connection with a multimillion-dollar Medicare fraud scheme. The PA wrote fraudulent prescriptions and orders for medically unnecessary durable medical equipment (DME; eg, power wheelchairs) and diagnostic tests, which were used by fraudulent DME supply companies and medical testing facilities to bill Medicare. The PA wrote the prescriptions and ordered the tests on behalf of physicians whom he had never met and who had not given their authorization. In this particular case, there was no blurring of the lines: It was a clear case of deliberate misconduct.
Now let me be clear: I am certain that these cases are rare and do not represent the high level of integrity that both PAs and NPs in our health care system have. Rather, I raise the issue so we can remind ourselves of the risks and ethical compromise that may emerge from engaging in questionable behavior, which may be motivated by profit-driven corporate pressure.
Remember, provided services billed to Medicare and other federal health care programs are only reimbursable if they are medically necessary for the diagnosis or treatment of illness or injury. In submitting claims to Medicare, providers must document the reasons for medical necessity and expressly certify that the services rendered were medically indicated and necessary for the health of the patient.
Submitting ineligible claims to a federal health care program constitutes a violation of the False Claim Act (FCA),1 even if you do not know they are ineligible or do not intend to commit fraud. Simply put, the government believes it is paying for services or items that have legitimate medical value when, in fact, the services or items are essentially worthless.
Here are some strategies2-4 for avoiding potentially fraudulent billing errors:
1. Make sure you have a Medicare provider number from the local carrier in your state. (This is required by federal law.)
2. Consult your provider relations representative to discuss regulations for reimbursement.
3. Know your codes! Ignorance of the coding system is not a defense if you are charged with fraud.
4. Check the accuracy of your coding service by having an expert periodically evaluate a few of your charts. Encourage your practice to implement a compliance program, with a focus on identification and prevention of problems with coding and billing.
5. Document the necessity of any ancillary service, and know the appropriate CPT codes.
6. Order only lab tests that are medically necessary.
7. Keep current; billing regulations change frequently and ignorance of the rules will not excuse you from liability. Encourage your state professional organization to invite a coding expert to speak to the group each year.