There is not a day that goes by when physicians and patients don't hear about the arrest or legal action taken against physicians accused of health insurance fraud. Having one of Medicare's recovery audit contractors (RACs) or a private healthcare insurance entity such as Blue Cross and Blue Shield come in and audit your billing records can be very frightening.
Most physicians attempt to bill their claims correctly and with due diligence. However, there are a few providers -- and people who employ them -- that have other intentions, which can not only be harmful to a practice but also can suck in other physicians that rely on the integrity of the billing company and the entity in which they work as an independent contractor or employee.
Violation of the False Claims Act -- resulting from fraudulently billing Medicare or Medicaid -- can result in civil penalties from $5,000 to $11,000 per fraudulent claim. In addition, the provider is subject to paying back three times the amount owed from the fraudulent claim. Of course, this does not include attorney fees to defend yourself against such allegations, as well as the income lost due to spending time on such matters.
My Story
If that is not enough to scare you, my personal experience should heighten your level of scrutiny. I signed a 3-year contract to work for an urgent care center. My contract stated that if I broke the contract and left early I would have to pay $22,500 plus $1,200 for each shift that I was to work in the future 60 days. I averaged 18 shifts a month. At the time I signed the contract, the clinic had a certified coder on staff and we were using paper charts.
In the next year, electronic health records (EHRs) were implemented and we were told that the certified coder would personally review the CPT coding of the charts regardless of what the EHR system coded. The practice administrator, who was also a part-owner, started rigging the EHR system to upcode claims to a 99215 (Level 5 office visit). She did this by having the triage staff enter in three complaints and ensure that every review of systems (ROS) was addressed at each visit.
When we questioned her about the high level of codes being generated by the EHR, she indicated that the certified coder was reviewing and making adjustments accordingly. Management indicated that they wanted a very thorough chart which charted every ROS every time the patient was seen. According to the triage staff, they were coerced into documenting three complaints even if the complaints were not actually verbalized by the patient.
In addition, the owner indicated that physicians should document all previous and current diagnosis codes on the chart in the encounter. I explained to her that this should be in the problem list and that the diagnoses should not all be included for billing purposes. She rejected the idea of a problem list and indicated those codes needed to be in the diagnosis and plan section of each encounter.
This really raised my suspicions and I sought to talk to the certified coder and the office manager for clarification on coding adjustments. On or about this time, I got word that Blue Cross and Blue Shield was conducting an audit of the physician owner.
I was barred and denied access to my billing records at this clinic by administration/owner and the billing staff. The certified medical coder was told not to speak to me and to avoid talking to me about any concerns.
I was told in confidence that the physician who owned the practice had to recently pay back a sum of money to Blue Cross and Blue Shield; the certified coder, who eventually told me of her concerns of billing fraud, was fired. She was barred from making the correct coding adjustments.
The physician who owned the urgent care indicated that the certified coder had made mistakes and she was terminated. In light of his statement, I asked the physician owner directly three times to see my billing records and he indicated that he could not let me do that. I asked him why and he indicated it was for financial reasons.
I also said that I could not put down diagnosis codes that were not addressed during that clinical visit. The physician owner was visibly upset and disagreed with me, demanding that I comply.
Held Hostage by the Contract
I felt at that point I was being held hostage by an employment contract. I could not, in good conscience, allow any additional medical claims filed under my provider number without being able to ascertain that my provider number was being used appropriately.
I resigned immediately after being denied access to my billing records. I could not allow additional diagnosis codes to be used in the chart when I did nothing to address those medical conditions. I also found that some of my charts had been edited with additional diagnosis claims I did not authorize.
A colleague and I are now being sued by the clinic for "breach of employment contract" for terminating our relationship with them early. The clinic is seeking damages in excess of $60,000, plus attorney costs.
Physicians worry about medical malpractice suits all the time; however, on many occasions, this is the least of their worries and they just don't know it. Medical malpractice insurance does not pay for fraudulent claims. This is why an ounce of prevention is worth a ton of cure; your reputation, medical license, and provider numbers can be put at risk without your knowledge.
Can This Happen to You?
You may ask, "How can that happen to me?" I hope I have showed exactly what can happen if you put your head in the sand and don't take notice. You can be stuffing the pockets of your employer and be held liable for money you did not know you earned. In other words, you can be hung out to dry and fend for yourself in the wake of audits by RACs and private insurers.
If you work as an independent contractor or employee for an entity, and that business is billing Medicare, Medicaid, and private insurance on your behalf, you can be at risk if you are not involved in the integrity of the billing. These entities may be billing patients and collecting co-payments on your behalf, and you have allowed them to deposit your insurance reimbursements into their corporate bank accounts.
Many of us who work as independent contractors or employees get paid an hourly basis when working in the emergency room or urgent care setting. If you are an independent contractor, you are held liable for false claims at higher scrutiny than those that are employees of the entity. Employees will be protected during audits, where independent contractors are left to fend for themselves.
Are you being held hostage by an employment contract? It is when entering into an employment contract and to ensure that you have access to your billing records as set forth by the Medicare rules. that during reassignment of benefits, physicians can have unlimited access to their billing records.
For further guidance, please read from February 2012; additional resources are listed . If a prospective employer is not amenable to letting you see your billing records, run away from that prospective relationship as fast as you can.
If you are an independent contractor, it is imperative that you get involved in the integrity of the billing. Entities that hire independent contractors can use their provider number to upcode and bill false claims at your personal liability expense.
My case is currently pending in circuit court, but I would rather face a civil lawsuit from breach of employment contract than face federal charges of Medicare fraud.
The writer's full name and location have been withheld due to involvement in pending litigation.