A Tennessee family physician and his practice have paid $285,000 to resolve allegations that they violated the False Claims Act by improperly charging Medicare, Medicaid (TennCare), and TRICARE healthcare programs the higher physician’s rate for services provided by unsupervised nurse practitioners. The billings in question occurred from 2013 through 2019.
Medicare and TennCare reimburse at the higher physician rate for services provided by nurse practitioners or other non-physician providers when the services are rendered “incident-to” a physician’s services, but only if the physician provides direct supervision. TRICARE always pays a reduced rate for services rendered by non-physician providers, regardless of whether a physician supervises.
Under the False Claims Act, any person who presents false claims for payment to the United States is liable for three times the damages the government incurs as a result of the false claims and penalties ranging from $5,000 to $22,363 per violation, depending on when the violations occurred.
Compliance Perspective
Issue
Submitting improperly coded bills to state and federal healthcare programs may be considered a violation of the False Claims Act, result in potential exclusion from the programs, with the assessment of monetary penalties for up to three times the damages incurred by the government.
Discussion Points
- Review policies and procedures regarding the appropriate billing codes for reimbursement from government healthcare programs, including MDS coding.
- Train staff involved in the coding and submission of claims to ensure that the proper codes are used regarding services provided.
- Periodically audit claims submitted for services to ensure that the proper codes have been applied and are consistently supported by accurate documentation.
FOR MORE INFORMATION ON THIS TOPIC: FRAUD MODULE 3 – MASTERING LEGAL IMPLICATIONS AND ANTITRUST LAWS
