You’re with a patient. More are in the waiting room. There’s a commotion. Men in uniform sweep into your office and a guy in a suit brandishes official looking paperwork in your face. As they execute their search warrant, they take photographs, your computer, and some patient files. Then they leave you in a state of shock.
Think I created the above scenario to get your attention? Sorry to disappoint you. Over the past few years, scenarios like this are becoming more common. And you won’t see your colleagues blog about it either. Once they’re caught in the spotlight, it’s all they can do to catch a breath. It could have been local law enforcement, but it’s more likely state or federal. For instance: DHHS/OIG, better known as the Department of Health and Human Services, Office of the Inspector General.
I know what you’re thinking. This goes way beyond an audit. These doctors must have done some pretty brazen things to merit a search warrant! I’d never do anything like that. Criminal? Fraud? Not possible! Guess again. It’s easier than you think.
One of the simplest ways to head down the path ultimately labeled “fraud” is your CPT codes. What problem could possibly result from your codes? Imagine that a CPT code you use regularly isn’t getting reimbursed. You’re buddy, Bob, let’s you know that he’s having better luck with a different code. Or perhaps your management consultant provides something better. The alternate doesn’t seem too different, so you switch. Later, this becomes part of your defense argument as you protest your innocence during talks over a two year period with the investigators sifting through your data.
Let’s look at an example. Suppose that 5 years ago you began using 97012 as part of your office visit to account for extended time with the patient. Today, you wonder why the investigators photograph your office as part of their intrusion. And later you learn they’re looking for mechanical traction equipment – which you don’t own. You tell your attorney that every chiropractor you know locally is using that code. Though the investigator is more sympathetic than you believe, her opinion is ultimately a simple one. At some point, it’s up to you to take responsibility for the CPT codes you submit on claim forms. And this code doesn’t reflect the service you actually provided. Since you don’t even own mechanical traction equipment, you committed fraud in the eyes of the investigator. If you had provided extensive manual traction and recorded this in your notes regularly, you might convince the investigative team that the coding error was a mistake as opposed to fraud. Of course, that won’t relieve you of penalties and fines. And let’s not forget about the future. One of the biggest potential problems you will have here is the damage to your reputation.
In the above example, you can be sure that the investigators will interview your patients and get depositions to bolster their case for court or a plea agreement. Imagine what that does to the local grapevine. The bottom line is: make sure you can justify the CPT codes you use daily.
Remember, if everyone is speeding on the highway, and you get pulled over because you’re doing it too… Finally, everything you’ve read here is relevant to recent investigations – not hype to get your attention. Be careful out there.
© 2010 Mike Norworth
About the Author
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 health care providers, equipment manufacturers, corporations and management consultants for over two decades with regard to business practices, operations and technical issues.