Quiz: Know your fraud
By Daniel J. Osborne

Certain billing practices and activities draw suspicion from healthcare payers. When it comes to billing, good intentions —

that is, not intending to cheat — do not count. Billings and practices that do not follow the rules invite investigations for fraud or abuse.

It is essential for healthcare practitioners to know what constitutes fraud and to take steps to avoid ambiguous practices.

Patients, the chiropractic profession, and America’s healthcare system suffer when practitioners engage in fraud and abuse. Intentional deception or misrepresentation for profit constitutes fraud. Charging for services that are not medically necessary, do not conform to professionally recognized standards, or are unfairly priced constitutes abuse.

The difference between the two is that intent to deceive cannot be established in cases of abuse. Actions such as these are not only costly and unethical, but also detrimental to the reputation of chiropractic.

TRUE OR FALSE quiz

Answer True or False to the following questions to refresh your knowledge of fraud.

You could raise a red flag that invites a fraud investigation if your practice …

1. T F Uses extensive marketing efforts that include free healthcare services to attract new patients.

2. T F Reports extensive time-based services provided with minimal licensed staff.

3. T F Unbundles billing for diagnostic testing (e.g., range of motion and muscle testing) by performing and reporting on visits following an exam.

4. T F Avoids the use of an unlisted service or procedure (CPT) code for services or procedures performed that do not have a specific assigned CPT code because unlisted codes may not be paid.

5. T F Determines the appropriateness of its practice activity based on what it perceives “everyone else is doing.”

6. T F Uses and relies on consultants who advertise promises of huge increased revenues.

7. T F Fails to document adequately all healthcare services rendered in the patient’s clinical record.

8. T F Misrepresents in-network services provided as if the credentialed provider rendered them, when, in fact, a non-credentialed provider did.

9. T F Uses mobile diagnostic testing services for specialty diagnostic testing.

10. T F Seems to have been created as a multidiscipline practice to circumvent third-party payer restrictions or limitations on reimbursements of chiropractic services.

ANSWERS

1. TRUE. Offering free healthcare services to attract patients may raise questions about the medical necessity of subsequent billed services and result in allegations of medically unnecessary and substandard healthcare services that are based on a patient’s insurance. Further, such activity may be contrary to federal or state laws.

2. TRUE. Time-based services are those that indicate a licensed provider administers the service one-on-one with the patient. An insufficient number of licensed staff could be an indication that the time-based services are not being administered by a licensed provider, are being administered for less than the indicated time, or are not being administered one-on-one.

3. TRUE. This activity could result in allegations that the testing administered in such a fashion is done for the purpose of expanding reimbursement potentials, since these tests, if reported separately on the exam date, would be seen as unbundling components of the exam service.

Remember that diagnostic tests are an extension of the exam and are performed to gain information not already known. This activity raises questions such as, “Do the specialty diagnostic tests performed on visits following an exam provide information that is not already known?” and “Do they have an impact upon treatment decisions?”

4. TRUE. This billing practice is extremely problematic and could result in allegations that CPT codes were reported that misrepresented the nature of the service actually provided.

It is your responsibility to learn how to report new diagnostic or treatment devices that have no specific CPT code assigned. The Current Procedural Terminology (CPT) manual instructs providers using the CPT coding system to pick the code that most accurately identifies the service or procedure performed, including the use of unlisted service or procedure codes with a description of the service or procedure performed when a specific code is unavailable.

Remember that the primary purpose of CPT is to facilitate the accurate reporting of services rendered.

5. TRUE. If you are a practitioner who benchmarks the appropriateness of practice activity on what everyone else is doing, you could soon find yourself the target of a fraud investigation. It is critical that sound reason and judgment be used in all practice decisions that are based on the laws and rules governing healthcare.

6. TRUE. “Trust but verify” is the key here. Trust that you are being instructed properly on what practice activity will increase your income, but verify that the instruction provided is consistent with ALL relevant laws, rules, and regulations that govern healthcare before you implement these practices.

7. TRUE. If it is not documented, it did not happen. Poor documentation could result in allegations that you billed for services not rendered, that you billed for services that were substandard or medically unnecessary, that you billed for services that misrepresented the nature of the service provided, or that you billed for services that misrepresented the service provider.

8. TRUE. This practice could result in allegations that you billed for services that misrepresented the actual service provider. Pay close attention to contracts or agreements signed with payers and be familiar with all participation requirements and restrictions.

9. TRUE. It is not illegal to use mobile testing services, but the relationship you establish with the vendor must be consistent with all federal and state laws and rules. This activity could result in allegations that medically unnecessary services were administered to the patient if it is determined that a potential “kickback” relationship exists in which the referring provider is financially rewarded by the lab company for the testing referral.

Have your own legal counsel review the relationship prior to its inception and implementation.

10. TRUE. If the practice setup and structure facilitate reimbursement for services that would otherwise be non-covered, it produces a big practice risk that could result in allegations that the practice billed for services misrepresenting the actual service provider, etc.

Consult with experienced legal counsel or other compliance resources to ensure that your multidiscipline practice is set up and operating consistent with the laws and rules.

Daniel J. Osborne, MS, has been involved in the identification and investigation of healthcare fraud for approximately 20 years. He has published numerous articles on healthcare fraud and compliance subjects and is on the Fraud Committee for the Federation of Chiropractic Licensing Boards and the Speaker’s Bureau for NCMIC. He can be contacted by phone at 913-369-9000 or via e-mail at Cccpfc@aol.com.