Can you change a billing diagnosis?
By Deborah Green, Esq.

To secure a better coverage for my patients from their HMOs I have occasionally changed the official billing diagnosis or reported symptoms that the patient did not have, in order to improve the number of services I could provide to the patient. What is the downside of doing this?

The downside is serious: You are filing a false or inaccurate bill — a deceptive practice that violates the False Claims Act.

Such a violation carries with it both civil and criminal penalties, including three times the actual damages and up to $10,000 per false claim submitted. Even if you are not dealing with Medicare or Medicaid or other federal entitlement plan, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) makes fraud committed against private payors a federal crime under certain circumstances.

Private payors may also turn to state Racketeer Influenced Corrupt Organizations Act (RICO) with respect to healthcare fraud, which includes wire or mail fraud. Such claims may make you liable for a number of civil and/or criminal penalties.

Additionally, if you falsify a chart, and then you do not follow up with the appropriate treatment for that patient, you could be liable for malpractice.

The managed-care organization I work with constantly delays payment to me. Is there anything I can do?

Currently 21 states impose civil money penalties on plans if they do not pay you on time. Generally, plans have between 15 and 60 days to pay claims under the “prompt pay” laws.

Plans are required to pay only “clean” claims in that period, so learn what constitutes a clean claim. Make sure that definition is in your contract with the plan.

The following steps will most likely help you achieve the quickest claim processing possible:

1. Bill electronically;

2. Define the payment time in the contract regardless of whether you are located in a prompt pay state;

3. Define clean claims in your contract;

4. Dedicate staff to oversee the entire billing process.

5. Set up a system in your office so that you know what each payor requires in order to pay promptly. Take the time to read the payors' manuals and set up a template for each particular payor. This would avoid the delay of resubmission of claims.

6. Audit your own outgoing claims. Your staff may overlook certain codes on the claim, which can ultimately cost you thousands of dollars. Review about 15 files per month and find the problematic areas.

7. Follow up on claims. If claims are not being paid with-in a set amount of time, call the payor and find out why. Use a computer program that follows up on “slow pays.”

Do not resubmit claims as a matter of course. This merely gives the plan that much longer to pay you. Demand to know where the claim is and why payment has been delayed. If you still send claims on paper instead of electronically, send them certified letter or hand delivery. If the plan insists the claim was lost or never sent, fax it over.

Every so often I receive a letter from a disgruntled patient threatening a law suit. So far, none of them has followed through. Do I need to notify my insurance carrier of these letters?

Most policies require that you advise them of any claim or suit alleging injury as soon as possible. In most instances, you need to provide your insurer with written notice. This is absolutely the case if you are served with a lawsuit. Failure to provide this notice to the insurance company or to attempt to settle the lawsuit on your own, may result in your losing insurance coverage.

Direct questions to Deborah Green, Esq., at healthattorney@aol.com or call 954-971-7778. Ms. Green is licensed to practice law in New York and Florida. Her specialty is healthcare.

DISCLAIMER: This column is provided for educational purposes only, not as legal advice with respect to any matter. The accuracy or timeliness of the information presented is not warranted, and no attorney-client relationship is established.