Your Yellow Page section, in the latest issue, carried an account of charges brought by the Federal prosecutor involving Dr. Steven Cohen from North Carolina. ("No whirlpool, no good!") Although, on face value, it would seem the doctor in question must have committed some overt acts to have garnered these charges, someone more familiar with healthcare billing practices may see how these indictments were actually generated. Medicare has a manual available on the internet, entitled Medicare Program Integrity Manual, Chapter 2— Indentifying Potential Errors and Potential Fraud, regarding their fraud investigation criteria. It lists criteria that could trigger an investigation. Although Medi- care was not part of this investigation, similar standards were applied in this particular instance. The charges stemmed from three primary billing issues. At one time, this doctor was involved in a multidisciplinary clinic with a DC, MD, and PA, working under the MD's supervision billing for services, an arrangement that has come under extreme scrutiny lately by governmental agencies and third party payers. In this doctor's case, charges were separated by the treatment and particular provider involved. For some of the billing dates in question, verification of the presence of the MD or PA in the office had to be made through employment records, as the PA was now deceased. This was made more difficult by a regional flood that had destroyed the storage facility where they had been stored. Regarding the billing for services, which were allegedly not provided on the dates submitted, sign-in sheets provided documentation that showed that, in fact, most of these patients were present on the questioned dates at issue; however, many of the doctor's records had been destroyed in a flood and the doctor had not retained a separate back-up record indicating treatments and dates, leaving distant memories as the only evidence of very specific treatment details. This is a recipe for problems that underscores the critical importance of maintaining excellent, detailed records, including a backup computer system that records dates of treatment for patients in the event of loss of written documents. Regarding the "no whirlpool" charge: On checking with the CPT code books, ACA guidelines, and various state boards, indeed, the code chosen to describe the hydrotherapy bed was one that was recommended by all these agencies as well as the manufacturer at the time the claims were submitted. Because of the way the CPT description was written, it also included the word whirlpool. This led to a problem of interpretation with investigators. This is very important to note: You must document where the CPT code you choose to use comes from and if it meets your state board's standards. Keep any correspondence verifying this indefinitely. Keep records of any training seminars or continuing education hours to prove that you were "adequately trained" on a piece of equipment and thus "qualified' to bill" for this service. The new HIPAA regulations require that the most ...Continues on page 53 ► FORUM ...from page 8 accurate code be used. Dr. Cohen's CPT code was appropriate to describe the service at the time it was rendered. As CPT codes have changed since the original billing dates, there has been a different opinion that a new CPT code best describes the service. Can you see how this can generate future billing problems in all practices? Regarding the multiple billings, some claims had computer entries with inappropriate and/or primary information missing in areas like patient addresses. When an employee inappropriately keyed in someone's information, it was seen as a "false claim." This error may not have been caught on the first EOB's and uncorrected claims were resubmitted due to non-payment. If an employee makes an error entering a third party insurer's information into the computer then, anytime any patient's data is tied to that insurer, you will generate an error. If any clinic generates duplicate claims, they must be very careful to indicate on the paper claim that this is a corrected claim and not merely a resubmission, otherwise it is viewed as "double billing." (See Me.dle.arn Matters-lafannaJjonfor MedL care Providers from CMS Reminder to Slop Duplicate Billings, Number SE0415.) Whether or not a clinic has done anything inappropriate, many times their claims may be challenged for review. Any of these insurance claims that were disputed and sent by mail can cause a charge of mail fraud. In our capacity as billing and procedural consultants, we are aware of several cases around the country that are being investigated at this time with similar circumstances. Doctors must protect themselves and their practices by staying informed about legal issues involved with billing practices and the liability to themselves in instances where employee errors may create problems. In some cases, employees have reported billing problems to the authorities as a way of getting back at their former employer. This case is an example of how simple human errors in your practice and billing procedures can lead to an investigation that financially and emotionally drains the doctor and clinic. Monette Sexton, DC Professional Procedures AControl, LLC Reidsville, NC
