A former medical practice located in Frederick, Maryland, has paid the United States $850,949 to settle allegations that it submitted inappropriate claims to the United States for evaluation and management services. The settlement agreement was announced on September 12, 2023.
According to the settlement agreement, from January 1, 2013, to November 1, 2017, the practice improperly submitted claims for evaluation and management using a code modifier that is only appropriate when there is a separate and distinct evaluation and management service on the same day as a procedure or other service being performed on a patient. The practice submitted and was paid for those improperly billed claims when it did not perform a separate and distinct evaluation and management.
Additionally, the practice improperly submitted claims from January 1, 2013, to November 1, 2017, under the billing number of the patient’s physician rather than the non-physician provider who treated the patient in the physician’s temporary absence.
The civil settlement reached by the United States Attorney’s Office for the District of Maryland arose from an initiative inside the US Attorney’s Office, which involves the use of dedicated resources and personnel to review Medicare billing data. The review of that data has enabled the US Attorney’s Office to identify areas of concern where it appears that billing irregularities may have taken place.
“It is fundamental that a medical provider accurately bill for services that are actually provided,” said US Attorney Erek L. Barron. “The United States Attorney’s Office is committed to recovering monies for the federal healthcare programs and will hold practices and individuals accountable for their actions.”
“Accurately billing for services provided to Medicare beneficiaries is required of all healthcare providers,” said Maureen R. Dixon, Special Agent in Charge for the US Department of Health and Human Services, Office of the Inspector General (HHS-OIG). “HHS-OIG will continue to work with our law enforcement partners to investigative allegations of fraud in federal healthcare programs.”
Compliance Perspective
Issue
Providers must ensure that the claims they submit to Medicare and Medicaid are true and accurate. One of the most important steps a provider can take is to have a robust internal audit program that monitors and reviews claims. If a provider identifies billing mistakes in the course of those audits, the provider must repay overpayments to Medicare and Medicaid within 60 days to avoid False Claims Act liability. Providers also can disclose billing errors to the OIG through the OIG Self-Disclosure Protocol.
Discussion Points
- Review your policies and procedures for preventing and reporting false claims and for conducting a Triple Check Process to verify accuracy of Medicare claims. Ensure that your policies are reviewed at least annually and updated when new information becomes available.
- Train all staff upon hire and at least annually on your compliance and ethics policies and procedures and on what can be considered a false claim. Provide training to appropriate staff on the Triple Check Process for ensuring accuracy of all Medicare Part A billing and supporting documentation before claims are submitted. Members of the compliance and ethics committee should periodically receive additional training on compliance and ethics issues in healthcare. Document that these trainings occurred and file the signed document in each employee’s education file.
- Periodically perform audits to ensure all staff are aware of compliance and ethics concerns and understand their responsibility to report any potential compliance and ethics violations to their supervisor, the compliance and ethics officer, or via the anonymous hotline. Audit to ensure that the Triple Check Process is being followed each month before claims are submitted to Medicare, and that any identified irregularities are corrected.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
