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Gastroenterology Workshop: Part 2 Compliance Issues & Endoscopy Billing. McVey & Associates, Inc Sponsored by: NASPGHAN October 21 & 22 Buena Vista Palace Resort & SPA Orlando, FL. Presenter:. Kathleen A. Mueller, RN, CPC, CCS-P, CCC, CMSCS 204 E Locust St Lenzburg, IL 62255
McVey & Associates, Inc
October 21 & 22
Buena Vista Palace Resort & SPA
Dr. Smith is a patient in our practice.
Because he refers many of his patients to our practice, we never bill Dr. Smith, his staff, and other members of his family anything over what insurance pays for their services.
Professional courtesy is defined as "the
provision of free or discounted health care items
or services to a physician or his or her immediate
family members or office staff". Besides the
prohibition to Medicare patients, the following
rules apply to all other patients:
A patient presents to a hospital-based clinic complaining of blood emanating from his rectum and severe abdominal pain. As instructed, the staff hands the patient a clipboard with a patient registration form and asks the patient to complete the form which includes the patient’s insurance information. Only after the patient completes the form is the patient seen by the physician.
Any patient that presents to a hospital-based clinic in a potentially emergency situation must be given a screening examination before he/she is questioned regarding their health insurance.
Though our practice is very careful when it comes to billing Medicare or Medicaid for all applicable copays, coinsurance and deductibles, we do offer professional courtesy in the form of “bill insurance only” to commercial payors for services provided to the medical community.
It is a violation of federal law to submit a claim for payment for a service when the amount billed does not represent the amount that is actually charged.
Anti-kickback and False Claims apply to all “health care benefit programs”, federal or private.
The family of our patient, who was recently admitted to a nursing facility, asked if we could continue to see the patient in the nursing facility. Since we are not accustomed to seeing patients outside our office or hospital, and since the Medicare payment that we would receive would not be sufficient compensation for the travel time back and forth to the nursing facility, we asked the family to pay a nominal amount above the Medicare allowed amount to cover our additional costs.
Unless the physician “opts out” of the Medicare program, he/she can not charge more than the Medicare allowed, for participating providers, or the limiting charge, for non-participating providers, even if the patient is willing to pay more.
One of the drug reps that comes to visit our office with samples of her products, often will provide our staff with, pens, pads, and other small items. Once a month she brings lunch for the physicians and staff, often from a gourmet restaurant. For Christmas, she brings a pair of theater tickets for each of us.
Anything over $300 per year in total value is suspect.
The Practice has hired a nurse to manage our inflammatory bowel clinic. On occasion the physician is not in the office during the clinic hours. The Practice bills a 99211 for the nurse visit under the physician’s name.
The “Incident to” provision of Medicare allows a physician to bill for services provided by someone else assuming the following criteria are met:
A practice brings on a new associate. It takes several months before the associate receives all her insurance provider numbers. In the meantime, services provided by the new associate are billed using the provider numbers of another physician in the group.
Whether Medicare or any other private insurance carrier, a claim identifying the provider as one person, when in fact the person providing the service was someone else, is considered a false claim.
A patient calls the office wanting to be scheduled for a screening colonoscopy. The physicians in this practice feel strongly that the patient should be seen and examined prior to scheduling the procedure. The patient is asked for the name of her primary care physician. The visit preceding the colonoscopy is billed as a Consultation.
A Consultation in billing terminology requires a request from another physician for an evaluation of a specific problem. As the request was for a screening colonoscopy only, the visit can not be billed as a Consultation and the claim is a False Claim.
A patient received a procedure during which biopsies were taken and sent to the laboratory. The results come back negative. The nurse calls the patient at home and leaves the following message on the answering machine: “Mrs. Jones, this is Dr. Smith’s office. Your tests came back negative. Everything is normal. Call us to schedule an appointment for 6 months”.
HIPAA precludes the practice from leaving patient identifiable information on a machine that is not secure. This practice also violates state confidentiality laws.
An attending physician in a teaching hospital supervises a resident clinic. The attending only sees the patient when requested by the resident. The attending reviews and signs all the charts and bills for all the services provided by the residents.
For the service to be billable by the attending physician, he/she would have to see the patient and document his/her participation in each component of the service: History, Examination, and Medical Decision Making.
A practice receives a letter from Medicare requesting the medical record documentation for 10 services. Since the documentation was minimal or non-existent, the physicians destroyed the original documentation and dictated new documentation for the 10 services which were sent to Medicare.
It is prohibited for a physician to destroy or alter medical record documentation without identifying the change and the date it was made. Doing so is a felony.
The practice decided to withdraw from participation in a major managed care plan because they discovered that the out-of-network payment is considerably higher than the in-network payment. To minimize the out-of-pocket expenses of the patients, the practice waives the co-insurance.
The amount billed to the insurance company must reflect the amount that the practice intends to collect, including the patient’s responsibility. If the practice does not intend to pursue the patient for their responsibility, the insurance company can refuse to pay the practice for the service.
Because the insurance company does not pay for routine physical examinations, the practice gives the patient a statement indicating that the patient had symptoms, when no significant symptoms actually exist.
Changing the diagnosis to make a non-covered service into a covered service is considered fraud even if the practice does not stand to benefit.
Because the physician does not understand the billing and coding process, he relies on the biller to code the services. The biller uses the same level of service for all E/M services, resulting in upcoding for some and undercoding for others.
The physician has responsibility for the accuracy all services billed under his signature.
Our office is on the campus of the hospital. We pay a token rent and the hospital provides the support staff. We bill “place of service”, “office”.
1. The Hospital is providing something of value (reduced rent and staff) in exchange for referrals.
2. The Physicians are referring to hospital (designated health entity) where they have a financial interest (subsidized rent and staff).
3. The physicians are Billing “place of service”, “office”, when the practice does not incur all the overhead expenses.
Teaching Physician must personally document:
Examples of Unacceptable Documentation:
Examples of Acceptable Documentation:
Examples of Acceptable Documentation:
HIPAA gives us another major change
Esophagoscopy – limited to study of the esophagus.
Esophagogastroduodenoscopy (EGD) - including study of the esophagus, stomach, and either the duodenum and/or jejunum
Enteroscopy (PUSH)- Past the second portion of the duodenum, into the jejunum and up to and including the ileum.