You\u2019re with a patient. More are in the waiting room. There\u2019s 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.<\/p>\n
Think I created the above scenario to get your attention? Sorry to disappoint you. I was — as is often the case — part of the aftermath.\u00a0Once they take your computer, they come to me. Over the past decade, scenarios like this are becoming more common. And you won\u2019t see your colleagues blog about it either. Once they\u2019re caught in the spotlight, it\u2019s all they can do to catch a breath.<\/p>\n
It could have been local law enforcement, but it\u2019s more likely state or federal. For instance: DHHS\/OIG, better known as the Department of Health and Human Services, Office of the Inspector General.<\/p>\n
I know what you\u2019re thinking. This goes way beyond an audit. These doctors must have done some pretty brazen things to merit a search warrant! I\u2019d never do anything like that. Criminal? Fraud? Not possible!<\/p>\n
Guess again. It\u2019s easier than you think. One of the simplest ways to head down the path ultimately labeled\u00a0 \u201cfraud\u201d is your CPT\u00ae codes. What problem could possibly result from your codes? Imagine that a CPT code you use regularly isn\u2019t getting reimbursed. You\u2019re buddy, Bob, let\u2019s you know that he\u2019s having better luck with a different code. Or perhaps your management consultant provides something better. The alternate doesn\u2019t 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.<\/p>\n
Let\u2019s 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\u2019re looking for mechanical traction equipment \u2013 which you don\u2019t 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\u2019s up to you to take responsibility for the CPT codes you submit on claim forms. And this code doesn\u2019t reflect the service you actually provided. Since you don\u2019t even own mechanical traction equipment, you committed fraud in the eyes of the investigator.
\nIf 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\u2019t relieve you of penalties and fines.<\/p>\n
And let\u2019s 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.<\/p>\n
The bottom line is: make sure you can justify the CPT codes you use daily.\u00a0 Remember, if everyone is speeding on the highway, and you get pulled over because you\u2019re doing it too\u2026<\/p>\n
Finally, everything you\u2019ve read here is relevant to recent investigations \u2013 not hype to get your attention. Be careful out there.<\/p>\n
CPT Copyright American Medical Association. All rights reserved. CPT\u00ae is a registered trademark of the American Medical Association.<\/p>\n","protected":false},"excerpt":{"rendered":"
You\u2019re with a patient. More are in the waiting room. There\u2019s 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 … Continue reading