If the Doc Goes Down, Do I Go Down Too?
Kathy Mills Chang
Originally published in ANJC's journal
Let's say you're a CA in a practice that's under review, under audit, or, at the extreme end of the spectrum, under federal investigation. The doctor may have been unknowingly engaging in red-flag behavior, such as undercoding, overcoding, or submitting error-riddled documentation. In very unusual cases, the doctor may have been part of a scheme to defraud Medicare or private insurers.
It's no surprise to hear that there will be consequences for the doctor and the practice. Depending on the circumstances and whether there was simple wrongdoing (making mistakes) or also intent to defraud, the doctor may have to repay reimbursements or, in extreme cases of fraud, face being fined, jailed, and/or losing his or her license.
So what happens to you?
If you've been keeping up with chiropractic news, you already know that records requests and audits are on the rise. The chances of documentation errors and other red-flag activities coming to light are greater than ever. Many experts feel it's not a ques-
tion of whether or not a chiropractic practice will be audited, but when. So it's perfectly normal to wonder what happens to you if the doctor, deservedly or not, gets into some sort of trouble.
ííMany experts feel it's not o question of whether or not o chiropractic practice will be audited[ but when. 99
Here's what's important (and probably comforting) to know: no one is after you. Even if actual fraud were being knowingly perpetrated, the government isn't likely to do more than question you as part of its investigation. That's because it's the doctor—the decision maker—whose livelihood and reputation is on the line.
While you could conceivably be questioned, you're what the government considers a "low-level employee," i.e., someone who is required to do what they've been told and, as such, considered passive in any misconduct. Even front-line coders aren't likely to come under governmental scrutiny unless they were
actively involved in and financially benefiting from the misconduct.
What's "active involvement"? Here's a case in point. In Illinois, a coder for an in-home visiting physician group was convicted of making false statements. She had been knowingly making up information in order to submit claims for services that she knew good and well had never even taken place. She not only was caught, but she also got into plenty of trouble.
This, I feel confident in saying, is probably not you.
But just because you're unlikely to incur personal liability doesn't mean you should sit on your hands and do nothing. If you're worried about anything you've been told to do, it's important to bringthose concerns to your supervisor, the practice's compliance officer, or the doctor. Put your concerns in writing, and make sure that you keep a copy, as well as copies of any response and anything you're told to do or not to do.
Keeping this written record will help establish that you're not the decision maker, and you'll be on record as having expressed concerns. It's also important to note that if you handle coding or billingforthe practice
and are asked to generate claims for services you know weren't provided, you must refuse to do so in order to protect yourself from liability.
What if you are a decision maker in the sense that you made the active choice to code or bill in a certain way even after concerns were raised? Then it's even more important that you document the basis for your decision. Remember that civil and criminal liability requires not just wrongdoing, but evidence of your intent to defraud. If you made your decisions based upon the practice's compliance manual and practice policy, you can demonstrate that you were simply following your supervisor's or practice's directives and had no specific intent of any wrongdoing.
Kathy Mills Chang is a certified medical compliH ance sPecial¡sl (MCS-P) and certified chiropractic 29 professional coder (CCPC). Since 1983, she has '^B provided chiropractors with reimbursement and ’ compliance training, advice, and tools to improve the financial performance of their practices. Kathy leads a team of 15 at KMC University and is known as one of our profession’s foremost experts on Medicare. She or any of her team members can be reached at 855-832-6562 or [email protected].
