You’ve been accused of fraud. You’re past the adrenaline rush. But still frantic.
Initially, accusations and the threat of prosecution can be intimidating. Anyone who watches television knows the smartest and quickest thing to do is shut up and let your attorney handle questions. But once the initial fear has worn off, a popular tactic is to blame the computer system.
Let’s discuss that before we get into defensive techniques that will help stop some types of investigation in their tracks.
When you try the “our computer did it” defense, not only will the prosecution investigate, but you may find yourself in more trouble than when you started. Inevitably, the prosecution team will have computer experts (I’ve even dealt with FBI forensics investigators) contact the software company to help shed light on your claims. As forensics investigators comb through your data, their intent is to find evidence to establish guilt. They’re not looking for exculpatory evidence along the way.
I often intercede in such investigations to provide a more neutral tone—which works…sometimes. And if your claims are outrageous, the investigative team will figure this out. In fact, they may consider such claims to be obstruction. As a result, the investigation will grow tentacles. Patients may be deposed.
HIPAA compliant software can help prove your guilt, innocence, or shed light on employee malfeasance. (Of course, if your software isn’t HIPAA compliant, that’s an entirely different can of worms.) If you’ve made changes to cover up potential wrong doing, you’d better hope your software isn’t as HIPAA compliant as you believe it to be. If it is, investigators will be able to track changes, deletions, etc. that you don’t want them to see. Know your responsibilities.
If your computer has been spitting out CMS1500 forms for years, and you suddenly claim that you never saw a form, that’s a problem—for you. Though form signatures in most medium to large volume practices are rare, good software has the capability to provide preclaim reports that can be reviewed for accuracy. Not only will investigators check this, but they won’t accept the possibility that you accidentally and repeatedly billed the wrong codes and/or dates because of this oversight.
To take this one step further, when you’ve purchased the practice, you might think ignorance magically becomes a valid argument. And it might, if it was a short period of time and you can demonstrate that you corrected it. But three years later, it’s hard to argue that you never checked.
If you bill electronically, it’s more feasible to plead ignorance. This won’t get you off the hook, but if your goal is to plead stupidity, it will help your case with a sympathetic investigator.
As a side note, a practice that comes to mind in Oklahoma was almost driven out of business by software that was repeatedly creating duplicate bills. Simultaneous audits by multiple agencies almost shut them down. In this case, the office was completely unaware of the problem until the auditors arrived—yet another reason not to treat software products as interchangeable based on advertising hype. Fortunately, the problem was obvious, and the company admitted to it. Though reluctant to trust any software, the office got back on their feet with ECLIPSE.
So, we’ve discussed misplaced blame and the threat of bad software. (Remember, the programmers who created your software didn’t have to pass National Boards, may not even have undergraduate—let alone graduate degrees in Computer Science, etc.). Now, let’s look at one scenario and how to best avoid an audit.
Sometimes, audits are inadvertently triggered by patients. An elderly Medicare patient calls the insurance company to tell them she wasn’t in your office on a particular day. Medicare sends you a letter. You now have one easy chance to avoid an audit. Ideally, you have a manual paper & ink signin sheet that demonstrates the patient was indeed there. Note that a manual sign in sheet is best (I’ll explain in a moment). A digital signature history (the patient’s signature will vary over time) should be okay as well. Either of these should suffice as evidence that the patient’s memory is faulty. If you have alternate means of proof—such as a card swipe, don’t be surprised when your documentation is initially regarded as insufficient. You may find yourself in the position of having to prove that you can’t manipulate the data. And if you issue the cards to your patients… well… you get the picture.
Investigators are suspicious by nature. There’s a high expectation that computer related data can be manipulated. So, unless you have iron clad proof to the contrary—even if you ultimately triumph—this is a situation where old fashioned paper and pen may prove superior.
Finally, make sure your notes—whether you use travel cards or computer documentation—actually reflect what you did to justify the CPT codes you used. (By the way, a manual travel card with multiple service dates would also help you justify the above patient complaint.) Payers you submit to now use their computers to parse the data you send and look for anomalies. It may be several YEARS before they begin to look for a pattern that retroactively affects you (e.g. you code every visit to maximum duration & complexity).
If you keep good records and are reasonably careful with your coding, you’ll avoid queries that turn into audits, and worse.
About the Author
© 2010 Mike Norworth
With degrees in Biology & Chemistry, graduate degrees in Computer Science and over 25 years of experience in health care, Mike is the chief architect of ECLIPSE® Practice Management Software. He also has extensive experience with audits & computer forensics investigations at the local, state, and federal level. Finally, he has advised healthcare providers, equipment manufacturers, corporations and management consultants for over two decades with regard to business practices, operations and technical issues.