Fraud Effecting Employment

[mgriffiths]

Thankfully this is not me, but curious about other's input to prevent this type of situation.  Unfortunately I don't have all of the information, and I'm also not going to post specific details I do know to protect the privacy of this individual (and myself I guess).

Basically, it was recently found out that someone supposedly committed fraud using another medical provider's name (MP).  This MP has been with the same employer since before this potential fraud occurred, and hospital management is "confident" MP did not do this - I don't know how this has been verified or if it has.  Unfortunately I don't know the nature of the fraud, but I am assuming it is something medical as the MP's DEA has been suspended, and while the MP still currently has medical license and state license they are in jeopardy.  Also, all medicare/medicaid billing for the last several years is in jeopardy of not being paid out if it has not been paid already, and there is the potential for claw back of previously paid claims since the potential fraud occurred. Of course, private insurance claims would follow if medicare/medicaid set precedent.  As a result, MP is currently on administrative leave (I don't know paid vs. unpaid status), but since hospital administration clearly is supporting MP they are looking for some type of work that MP can do to be "helpful" that wouldn't involve patient care/billing/etc. until issue is resolved.

My question: how can we prevent this from happening?  One of the rumors circulating (valid or not) is that another provider in another office within our "greater hospital system" used MP's name for "medical stuff."  While I don't know my colleagues login information, honestly for some individuals it would be very easy to learn.  But, furthermore I could easily put orders and scripts in using another provider's name using my own login.  It would show that I am the one putting them in, but the orders/scripts still have the other provider's name.  In the present, this would easily be resolved as they can track keystrokes, but even a few years ago the logs were not as strict.  The bottom line, fraud is everywhere, medical or otherwise.  I recently changed jobs because of rampant billing and employment fraud and we read about it in the news pretty regularly.  So, how do we prevent this from happening to keep our own licenses and therefore our ability to work from being in jeopardy?  This MP claims to have no knowledge about any of this, and assuming MP is truly innocent that would obviously make sense!

[sas5814]

i wish I could say this was rare but I don't even think it is uncommon. Upcoding and such happens so frequently it has become part of the gestalt of the profession. I have never worked anywhere that didn't push and pull on billing and coding so that, at best, it was uncomfortable and , at worst, it was outright fraud.

In my current position my medical director let us all know we were expected to charge 04 level visits 75% of the time at minimum and if we didn't our evaluation and raises would be affected. I asked for the source of this and was told it came from the VP of clinical services who is a physician. I asked for that in writing. When he wanted to know why I told him that an organization mandating a certain percentage of 04 visits under duress is the very definition of conspiracy to commit fraud. I wanted it in writing. I never got it and the issue faded away but I was advised I was "getting a reputation" which I assumed wasn't good.

I think all we can do is be vigilant and, when confronted with something that doesn't pass the sniff test, ask for verification and written responses. In the age of electronic records and never ending security issues we can only be careful.

[CAdamsPAC]

6 minutes ago, sas5814 said:

i wish I could say this was rare but I don't even think it is uncommon. Upcoding and such happens so frequently it has become part of the gestalt of the profession. I have never worked anywhere that didn't push and pull on billing and coding so that, at best, it was uncomfortable and , at worst, it was outright fraud.

In my current position my medical director let us all know we were expected to charge 04 level visits 75% of the time at minimum and if we didn't our evaluation and raises would be affected. I asked for the source of this and was told it came from the VP of clinical services who is a physician. I asked for that in writing. When he wanted to know why I told him that an organization mandating a certain percentage of 04 visits under duress is the very definition of conspiracy to commit fraud. I wanted it in writing. I never got it and the issue faded away but I was advised I was "getting a reputation" which I assumed wasn't good.

I think all we can do is be vigilant and, when confronted with something that doesn't pass the sniff test, ask for verification and written responses. In the age of electronic records and never ending security issues we can only be careful.

Sadly I suspect that this isn't an aberrant activity and that standing up for what's right is!!

[mgriffiths]

Absolutely regarding a situation like that, and the fraud I changed jobs over was the actual changing of my billing codes without my input.  Then by changing my billing it effected my RVU bonus, which could be deemed withholding income.  It was a mess, and so glad to be away from there.  But, even the billing codes being changed was found simply by accident and then was eye-opening once I actually started looking.

[rev ronin]

12 minutes ago, sas5814 said:

In my current position my medical director let us all know we were expected to charge 04 level visits 75% of the time at minimum

See, this is a bit different than fraud.  I'd say 90% of my visits meet RISK level criteria (2 stable chronic illnesses, new illness with systemic effects, rx management, or a chronic illness progression or exacerbation) for 99204/99214.  At that point, they're demanding you do the H&P to make such a visit a -4 level, which is arguably reasonable, especially for the 99214 level, which only requires H or P to the -4 level, not both.  I routinely collect and document 10+ HPI elements, and everyone is asked smoking status every visit by the MAs so that's PFSH covered, and the per-visit form asks ROS for that specific day.  So, if I have a 99214 level visit that I UNDER code as a 99213, I'm arguably committing fraud as well! Ridiculous? Absolutely.

[sas5814]

yea under coding is supposedly as bad as over but I have never seen anyone charged for under coding.

My "leaders" changed their tune to the industry average on UC visits is 75% 04 level and that is our goal. That was reasonable. Teaching people to improve their charting to maximize coding is reasonable. Having billing ask us if there are other elements that could be included to meet a criteria is reasonable.

Telling people their job is on the line is duress and when the leadership team gets together to do this it is conspiracy. I had a simple question... would they be comfortable if I wrote CMS a note about their policy just to make sure they were OK with it? *crickets chirping*

Let me add he gave us a pile of manure about how the UC was there when everyone else was closed and we work weekends and holiday so we were entitled to that higher revenue. It was a giant pant load. None of that has to do with the visit level.

 

Edited April 30, 2019 by sas5814

[ventana]

more going on here...

DEA suspended

License in jeopardy....  this is not just an coding issue but instead a prescribing issue as DEA got pulled first

 

How do we prevent this

1) protect your passwords

2) strive for total professional independence for billing reasons - no more "incident to" and 100% access to your billing and collections

3) don't be afraid to move on in a crappy organization

 

 

 

[EMSGuy1982]

In my area there were people attempting to call clinics posing as pharmacy employees asking for NPI/DEA license numbers by our nursing staff. Thankfully our information was not given out although our NPI’s are public. Another incident involved someone calling multiple pharmacies posing as an MA/LPN/RN from a “clinic” attempting to call in a prescription for a controlled substance using a fellow colleagues DEA/NPI information half way across the state. Unfortunately I don’t think this is a rarity. Protect your information as best as you can. I’m even wary that my DEA number is printed on Rx paper when I do prescribe. I did have one person at my previous job who took a script I gave him and tried to alter the amount. I was sent a copy and it was painfully obvious that they tried to tack on a few zeros. It was laughable but definitely shocking. To the OP; if your colleague in fact is innocent time will tell. It sounds like it should work itself out though I’m sure the whole ordeal is taxing on them. 

 

 

[KpsPac]

9 hours ago, sas5814 said:

yea under coding is supposedly as bad as over but I have never seen anyone charged for under coding.

 

 

'Tis true. Spoke to a colleague whom was fined for undercoding..... Can't win.....

[mgriffiths]

UPDATE: so it seems that this was simple mistake of identity.  Two individuals with the same name (different race and birthdays) confused by medicare and medicaid.  Basically fraudster MP is a provider and committed bank fraud in some way that affected insurance payouts.  Therefore medicare and medicaid went complete scorched earth and anyone named "MP" was caught in the path.  Unfortunately, while it seems like a simple fix, nothing is with Medicare and Medicaid.  They are refusing to accept the error, so it's headed to court.  Thankfully the hospital is supporting MP and has hired MP a lawyer, but that is also self-preservation for the billing both past and present.

[Cideous]

56 minutes ago, mgriffiths said:

UPDATE: so it seems that this was simple mistake of identity.  Two individuals with the same name (different race and birthdays) confused by medicare and medicaid.  Basically fraudster MP is a provider and committed bank fraud in some way that affected insurance payouts.  Therefore medicare and medicaid went complete scorched earth and anyone named "MP" was caught in the path.  Unfortunately, while it seems like a simple fix, nothing is with Medicare and Medicaid.  They are refusing to accept the error, so it's headed to court.  Thankfully the hospital is supporting MP and has hired MP a lawyer, but that is also self-preservation for the billing both past and present.

What a freaking nightmare.

[mgriffiths]

19 minutes ago, Cideous said:

What a freaking nightmare.

Abso-freakin-lutely!

[mgriffiths]

Final Update: the situation has been corrected!  Still a nightmare though.

[surgblumm]

We have not established any fact on the supposed fraud of this individual, therefore, it is best to suspect, not be a detective and read the newspapers. Fraud is a dangerous word and is a real and current danger for any PA that has another entitity submitting bills for their services. That may be a key component in the future if  OTP becomes a reality. OTP will cut out the additional potential layer of danger. How many orthopedists may dictate a fraudulent operative report or plastic surgeons, a false operative report for "hernia repair" that is indeed an abdominoplasty. Every specialty has their favorite possible false claims and if you are not submitting the bill then you have no idea what procedure was billed for. Another layer of protection is a personal liability insurance policy like the one I purchased from CM&F. If your employer makes a false claim, they sure as hell will not defend you in court. What individual protection do you have that will stand in for you personally. think about it.