DRG Coding Advisor
Consultants’ billing advice can attract fraud cops
Be skeptical about aggressive coding
A recent report from the General Accounting Office (GAO) waves a caution flag at providers about following the advice of reimbursement and coding consultants that seems to manipulate claims just to increase payment, without regard to medical necessity or standard billing procedures. "This aggressive and unethical approach puts the [physician] client . . . at substantial risk," Lewis Morris, assistant inspector general for legal affairs with the Department of Health and Human Services, testified before Congress. "Ultimately, providers need to recognize that hiring a consultant does not relieve them of the responsibility to ensure the integrity of all their dealings with Medicare and Medicaid," he warned.
GAO used undercover agents
As part of its investigation, the GAO sent a doctor and a criminal investigator undercover to two workshops and a seminar conducted over the past year by reimbursement consultants. In its report, "Consultants’ Billing Advice May Lead to Improperly Paid Insurance Claims," the GAO concluded the workshops offered advice that could open physicians to fraud investigations if they followed the billing suggestions. According to the GAO, among the questionable advice given at the conferences was that physicians:
• not report or refund overpayments from insurance carriers;
• provide tests and procedures that were not medically necessary so they could bill at a higher level, while creating documentation to support the higher charge;
• give patients with low-paying insurance, such as Medicaid, appointments at inconvenient times during the day that are usually hard to fill. In a related action, the Office of Inspector General (OIG) has issued a special advisory for physicians on the best way to spot consultants selling questionable advice. It suggests you should be wary of any consultants who:
• claim they have a special relationship with or "inside" connection at Medicare or the OIG;
• claim their services or products are approved or recommended by Medicare, the Centers for Medicare and Medicaid Services, the Department of Health and Human Services, or the OIG;
• guarantee specific results that are unreasonable or improbable through legal billing;
• encourage aggressive billing schemes or other unreasonable practices that are fraudulent and abusive;
• recommend you not cooperate when told some of your claims are going to be audited.
Bottom line: If what a consultant is promising you sounds too good to be true, it probably is.
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