In your opinion, has a Medicare billing violation occurred? Describe the legal concepts of “up-coding” AND “incident to billing”. Then, analyze the facts using both of these legal concepts to explain why you think there was a violation or why you think there was no violation.

QUESTION

Sam is a new Nurse Practitioner (NP) in an independent physician-owned primary care office located in a small community. He loves working with the patients and gets along very well with his coworkers. Normally, Sam will see a patient on his own, or with a female nurse, if the patient is female. However, Sam recently noticed that his time with a patient was coded and billed to Medicare as one of the physician’s time. He recalled the legal course in nursing school about Medicare and knew that NP’s time is reimbursed at 80% of the actual charge or at 85% of the physician’s fee schedule amount, whichever is the lesser. He also remembered that the physician he was billed under was not in the office that day. Being concerned, he reviewed some additional records and discovered almost all of his time was coded and billed to Medicare as one of the physician’s time. When he questioned the billing clerk about the coding, her reply was “the Physician Assistant’s and NP’s time are always coded that way”. Sam believes this maybe fraud and does not know what to do. He needs the job, as there are not many opportunities for this type of work in the community. Plus, making this issue public could damage his reputation – making it difficult to find work in the medical field at all, it could also impact his co-workers, and ultimately reduce patients’ access to primary health care. Sam wants to know what to do.

1. In your opinion, has a Medicare billing violation occurred? Describe the legal concepts of “up-coding” AND “incident to billing”. Then, analyze the facts using both of these legal concepts to explain why you think there was a violation or why you think there was no violation.

2. Assuming there was a Medicare billing violation, what are the possible criminal AND civil penalties for the violation AND against whom could they be brought? Be sure to explain why the person you identified is subject to the penalty.

3. First, list ALL options Sam has in this situation. Then, using your list of options, what would you recommend Sam do at this point? Be sure to explain your recommendation in detail.

4. What VERY SPECIFIC internal safeguards should the office put in place to ensure proper billing practices?

ANSWER

Ensuring Proper Billing Practices: Internal Safeguards for Medicare Compliance

Introduction

Proper billing practices are crucial for healthcare providers to maintain compliance with Medicare regulations. Violations can lead to severe penalties, legal consequences, and damage to reputations. This article explores the importance of internal safeguards and provides specific recommendations for an independent physician-owned primary care office to ensure adherence to Medicare billing guidelines.

Implement Clear Coding and Documentation Policies

To prevent Medicare billing violations, the office should establish clear coding and documentation policies (Chen et al., 2020). These policies should outline the proper procedures for accurately documenting services provided, specifying the roles and responsibilities of healthcare professionals involved in billing, and ensuring compliance with Medicare guidelines.

Conduct Regular Training and Education

Continuous training and education are vital to keep staff members updated on Medicare billing regulations and procedures. The office should conduct regular training sessions focused on proper coding, documentation requirements, incident to billing guidelines, and up-coding awareness. Training sessions can be facilitated by internal staff or external consultants with expertise in Medicare compliance.

Perform Internal Audits and Reviews

Regular internal audits and reviews are essential to identify any potential billing irregularities or deviations from Medicare guidelines. The office should establish an audit program to periodically review billing records, coding accuracy, and compliance with documentation requirements. This will help identify and rectify any errors or potential violations promptly.

Utilize Technology and Electronic Health Records (EHRs)

Implementing an electronic health records (EHR) system can enhance billing accuracy and streamline the documentation process. EHRs provide built-in coding and billing functionalities, reducing the likelihood of human errors and ensuring proper documentation (Aguirre et al., 2019). The office should ensure that the EHR system is optimized for Medicare compliance and periodically review its usage to prevent system-related errors.

Foster a Culture of Compliance and Ethical Behavior

Creating a culture of compliance and ethical behavior is essential to prevent Medicare billing violations. The office should establish a code of conduct that emphasizes integrity, transparency, and adherence to regulatory requirements. Encouraging open communication channels and providing avenues for reporting potential violations without fear of retaliation will support a culture of compliance.

Engage a Medicare Compliance Officer

Appointing a dedicated Medicare compliance officer within the office can significantly contribute to proper billing practices. This individual should have a deep understanding of Medicare regulations, stay updated on changes, and oversee the implementation and monitoring of billing procedures (National Academies Press (US), 2003). The compliance officer can serve as a resource for staff, conduct regular compliance audits, and provide guidance on complex billing scenarios.

Conclusion

Adhering to proper billing practices is crucial for healthcare providers to maintain Medicare compliance, avoid penalties, and uphold their reputation. By implementing internal safeguards such as clear policies, regular training, internal audits, technological solutions, and fostering a culture of compliance, the independent physician-owned primary care office can significantly reduce the risk of Medicare billing violations. These measures will not only protect the office and its staff but also ensure patients’ continued access to quality primary healthcare services.

References

Aguirre, R. R., Suárez, O. V., Fuentes, M., & Sanchez-Gonzalez, M. A. (2019). Electronic Health Record Implementation: A Review of Resources and Tools. Cureus. https://doi.org/10.7759/cureus.5649 

Chen, Z., Hohmann, L. A., Banjara, B., Zhao, Y., Diggs, K., & Westrick, S. C. (2020). Recommendations to protect patients and health care practices from Medicare and Medicaid fraud. Journal of the American Pharmacists Association, 60(6), e60–e65. https://doi.org/10.1016/j.japh.2020.05.011 

National Academies Press (US). (2003). The Core Competencies Needed for Health Care Professionals. Health Professions Education: A Bridge to Quality – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK221519/