Advise: insurance fraud?

[EcstaticPanda]

So I usually hang out on the premed forums, but I got this job offer working in a psychiatric private practice. I went in for training and noticed many red flags with the psychiatrist. He charges $250 for medication management and psychotherapy to insurance (100 out of pocket) but spends less than 5 minutes with each patient. Patient files are paper but the only thing in them are printer paper that has a few scribbles on it (nothing legible, not like his actual hand writing). So my question is, is this insurance fraud? I am not going back there because of this and several things he said I found questionable or immoral.

---

Members don't see this ad.

 

[WisNeuro]

What codes is this person billing? At least for the notes, that would violate my state's healthcare records laws.

 

[EcstaticPanda]

90833 for psychotherapy and 99213 for medication management and follow up. Im in Connecticut.

 

[WisNeuro]

Well, you need between 16-37 minutes of therapy by itself to justify 90833. So if they're literally spending less than 5 minutes with a patient, that part would be fraud if correct.

 

[EcstaticPanda]

Ok, thank you for your help!

 

[Celexa]

When you read about law enforcement taking down pill mills, one of the things you almost always find mentioned is the volume and the fact that they could nail the provider on literally not being able to do the job in the time they spent with the patients, and/or lack of proper records.

Presumably this is because we get wide latitude on clinical judgment regarding prescribing to any individual patient, but a minute is a minute no matter who you are.

Massive red flags. I would get out.

 

[Bartelby]

Yeah, sounds like fraud. You are wise to avoid this practice.

 

[clausewitz2]

When you read about law enforcement taking down pill mills, one of the things you almost always find mentioned is the volume and the fact that they could nail the provider on literally not being able to do the job in the time they spent with the patients, and/or lack of proper records.

Presumably this is because we get wide latitude on clinical judgment regarding prescribing to any individual patient, but a minute is a minute no matter who you are.

Massive red flags. I would get out.

Prosecutors are not eager to bring cases that end up turning on dueling experts bickering over whether something is really optimally clinically or not. Don't need an expert when it comes to being able to read a clock.

There are probably more subtle frauds that fly under the radar but once you start detaching what you are documenting from any actual reality and reap the monetary benefits, seems like a lot of folks can't help themselves from pushing it as far as they can.

 

[FlowRate]

If the practice is also billing medicare, you could get yourself some sweet whistleblower payment from the government for reporting it.

Back of the napkin conservative estimate (if it were all medicare): 1000 clinical hours / 5 minute appointments = 12000 patient encounters * $50/encounter (lowball) = $600k * 10% (basically minimum medicare whistleblower incentive) = $60k

 

[WisNeuro]

If the practice is also billing medicare, you could get yourself some sweet whistleblower payment from the government for reporting it.

Back of the napkin conservative estimate (if it were all medicare): 1000 clinical hours / 5 minute appointments = 12000 patient encounters * $50/encounter (lowball) = $600k * 10% (basically minimum medicare whistleblower incentive) = $60k

(2) The amount of a reward represents what CMS considers to be adequate compensation in the particular case, not to exceed 10 percent of the overpayments recovered in the case or $1,000, whichever is less.

 

[Merovinge]

(2) The amount of a reward represents what CMS considers to be adequate compensation in the particular case, not to exceed 10 percent of the overpayments recovered in the case or $1,000, whichever is less.

Wait what, so the maximum is $1000 for any fraud case? That doesn't make any sense, why would anyone go through the agony for a capped payout of $1000.

 

[calvnandhobbs68]

(2) The amount of a reward represents what CMS considers to be adequate compensation in the particular case, not to exceed 10 percent of the overpayments recovered in the case or $1,000, whichever is less.

That's not the statute people typically use for whistleblower cases. What happens is people file a "qui tam" suit under the False Claims act where the government is actually the plantiff but you're initiating the suit.

False Claims Act

www.law.cornell.edu

 

[FlowRate]

(2) The amount of a reward represents what CMS considers to be adequate compensation in the particular case, not to exceed 10 percent of the overpayments recovered in the case or $1,000, whichever is less.

Not in the link I provided, but:

And because defrauding Medicare or Medicaid is also defrauding the US Government, any such suits also fall under the False Claims Act, which gives any whistleblower the power to file a qui tam suit on behalf of the Government as a relator. Relators are eligible for a portion of recovered funds from any such qui tam lawsuits, up to a cap of $66 million, which is awarded separately from any bounties paid by the CMS. Such incentives show just how dedicated the US Government is to fighting fraud.

Edit: posted at same time as calvin ^

 

[WisNeuro]

Not in the link I provided, but:

And because defrauding Medicare or Medicaid is also defrauding the US Government, any such suits also fall under the False Claims Act, which gives any whistleblower the power to file a qui tam suit on behalf of the Government as a relator. Relators are eligible for a portion of recovered funds from any such qui tam lawsuits, up to a cap of $66 million, which is awarded separately from any bounties paid by the CMS. Such incentives show just how dedicated the US Government is to fighting fraud.

Edit: posted at same time as calvin ^

Interesting, I stand corrected. Looking through stuff, seems that they go after large corps relatively regularly, but do they also initiate these types of suits against smaller practices?

 

[ObsequiousAplomb]

Interesting, I stand corrected. Looking through stuff, seems that they go after large corps relatively regularly, but do they also initiate these types of suits against smaller practices?

Pretty sure people go after individual dentists somewhat frequently, but maybe that's because I only remember the dentists.

 

[FlowRate]

Interesting, I stand corrected. Looking through stuff, seems that they go after large corps relatively regularly, but do they also initiate these types of suits against smaller practices?

No clue what the bar for prosecutors taking it super serious is. I feel like I've heard of at least a few individual physicians being charged and I think the amount of fraudulent payments they were pulling in per year from the government was somewhat similar to OP's case.

 

[Merovinge]

No clue what the bar for prosecutors taking it super serious is. I feel like I've heard of at least a few individual physicians being charged and I think the amount of fraudulent payments they were pulling in per year from the government was somewhat similar to OP's case.

I know of a doc that got busted for rampant fraud but it was not for cases like this where they will overbilling, it was for entirely made up services. I believe they are still in prison.

 

[mistafab]

The cases they DO go after are often so egregious it’s unbelievable.

Former Arkansas Medical Board chairman arrested on felony fraud charges • Arkansas Advocate

Dr. Brian Hyatt, the former chairman of the Arkansas State Medical Board, is wanted on felony Medicaid fraud charges.

arkansasadvocate.com

Excerpt:
“Investigators determined that Hyatt was present in the unit just 24 of the 46 days…The total time Dr. Hyatt was seen talking to patients or was in their rooms was less than 10 minutes out of a total of 2,671 minutes (.37%), the affidavit said”

 

[Candidate2017]

Wait. I know this is SDN, so jumping to conclusions is a favorite pasttime. But still, this is psych forum. Let's step away from the cliff before we jump to fraud.

I don't understand. You show up, first day on the job in some type of assistant capacity, and you suddenly know what this psychiatrist "charges" insurance? No one charges insurance. They get reimbursed, and the rate is highly confidential and protected by the insurance company (and each insurance company reimburses differently). I can interview for a clinic job and not a single person will divulge the exact reimbursement they get from a particular insurance company.

Also, I'm not aware of any insurances that accept paper charts. As far as I know, insurance requires EMR. What you describe sounds like a cash practice ($250 per quick med visit +/- "therapy", with $100 out of pocket for OON, no EMR, and illegible scribbles on paper with inverted T-waves).

And just the fact the rate has a zero on the end and is multiple of $50. Psychiatrists are not very creative with their cash rates, while insurance reimbursements are always some odd number like $99.43 for 90833.

 

[michaelrack]

insurance doesn't require emr, at least where I live

 

[TexasPhysician]

So I usually hang out on the premed forums, but I got this job offer working in a psychiatric private practice. I went in for training and noticed many red flags with the psychiatrist. He charges $250 for medication management and psychotherapy to insurance (100 out of pocket) but spends less than 5 minutes with each patient. Patient files are paper but the only thing in them are printer paper that has a few scribbles on it (nothing legible, not like his actual hand writing). So my question is, is this insurance fraud? I am not going back there because of this and several things he said I found questionable or immoral.

You can bill insurance companies any made-up number. I could bill $500, but they will still reimburse an agreed-upon contracted amount (less than what I bill). $100 out of pocket is the copay? Is this a cash or insurance practice?

Are you using a stop watch for each patient? It isn’t going to be 5 minutes on each patient.

For instance, I have patients that I can see in 2 minutes for 99213. That is normal. 90833 requires 16+ minutes of therapy. Generally a typical day will see a broad mix of codes.

Some clinicians will make brief notes and dictate/type in the chart later. A 99213 note is very simple.

Without seeing what is happening, it is hard to say how legit this all is. This is a very basic overview.

 

[Stagg737]

Wait. I know this is SDN, so jumping to conclusions is a favorite pasttime. But still, this is psych forum. Let's step away from the cliff before we jump to fraud.

I don't understand. You show up, first day on the job in some type of assistant capacity, and you suddenly know what this psychiatrist "charges" insurance? No one charges insurance. They get reimbursed, and the rate is highly confidential and protected by the insurance company (and each insurance company reimburses differently). I can interview for a clinic job and not a single person will divulge the exact reimbursement they get from a particular insurance company.

Also, I'm not aware of any insurances that accept paper charts. As far as I know, insurance requires EMR. What you describe sounds like a cash practice ($250 per quick med visit +/- "therapy", with $100 out of pocket for OON, no EMR, and illegible scribbles on paper with inverted T-waves).

And just the fact the rate has a zero on the end and is multiple of $50. Psychiatrists are not very creative with their cash rates, while insurance reimbursements are always some odd number like $99.43 for 90833.

I mean, if they're 5 minute appointments and the billing code for therapy used is 90833 then it's fraud either way. I think the real question is if the psychiatrist is actually doing anything illegal or if this is just unethical billing. If they bill CMS, it's obviously illegal. If it's cash only, doesn't matter. I honestly don't know if it's illegal to try and bill insurance for therapy when you're under time. I'm sure state medical boards would not take this lightly, but I'd be curious if actual charges could be filed.

Insurances will accept paper charts. I know of multiple places (private psych inpatient unit, SNF, at least 2 PPs) where I went to med school that only used paper charts and I know that psych hospital is still paper charts only.

 

[Bartelby]

I agree with Stagg, if the psychiatrist is submitting any document (including a superbill) with 90833 on it for a five minute visit then it's fraudulent. It is of course possible that the OP has misunderstood the situation though, for example a cash only psychiatrist simply charging $250 for a visit of any duration.

OP, do you know what billing codes were submitted and to who?

 

[WisNeuro]

insurance doesn't require emr, at least where I live

Likewise, in certain circumstances.

 

[EcstaticPanda]

I was told all patients that aren't self pay (100 for each visit) are billed 250 to their insurance and always with those 2 codes. I don't know if its illegal or not, I mostly wanted advice if it was as shady as I first thought.

 

[Mad Jack]

I was told all patients that aren't self pay (100 for each visit) are billed 250 to their insurance and always with those 2 codes. I don't know if its illegal or not, I mostly wanted advice if it was as shady as I first thought.

Seems sketchy

 

[TexasPhysician]

I was told all patients that aren't self pay (100 for each visit) are billed 250 to their insurance and always with those 2 codes. I don't know if its illegal or not, I mostly wanted advice if it was as shady as I first thought.

$100 for each cash patient is reasonable.
$250 billing insurance is reasonable.
Billing 99213 +/- 90833 is reasonable and often under-coding. Without a stop watch and tracking the time with each patient to verify not hitting 16 minutes for 90833, this is reasonable or under-coding. Most patients should be 99214.

If you see 12 patients per hour (5 minutes) and all 90833, insurance will audit the charts because this is an easy red flag. There isn’t 192 minutes each hour to bill this many 90833’s. Commercial insurances will catch this easily to address it with education, down-coding, refusing to pay that code, or whatever.

As you were there a brief period only, there isn’t much here that I would worry about. Unless you saw this MD billing Medicare fifty 90833’s per day, I wouldn’t think much of this.

 

[whopper]

Several insurances don't allow for charges outside of their reimburse, so if he's charging $100 in addition to what insurance pays this could be fishy. Other than this it's up to you. I wouldn't, however, make any formal complaints without solid evidence.

 

[KaiBuzz]

It’s not unethical to set your charges at a higher rate than Medicare, Medicaid, or commercial payers are willing to pay. The amount billed and what they are paid by commercial and government payers are two different things.

 

[whopper]

One of my patients reported another doctor cause he was doing one of the most high end drug tests available, and her insurance was billed over $1000 per test. I believe it was gas chromatogry drug tests. She kept testing negative at my office, but at this guy's office she was always positive. She told me that the other doctor told her that there must be something wrong with his machine and kept doing it.

Given that it kept happening, and he allegedly wasn't fixing the machine I told her she should report this. Turned out the guy was running a scam making several hundreds of people do drug tests and the insurance would only pay for more testing if there was a positive test. Then as this guy was being investigated, several of his partners in crime went for immunity deals where they confessed they sent people to him and he gave them a slice of the pie, and intentionally put dirty samples in the machine so they knew the insurance would continue to allow for reimbursed tests. The guy is currently facing serious criminal charges, but still remains in practice. I'd put a link up to show this guy and the several local news articles, but the case is still pending so I don't want to take any HIPAA risk by putting his name up.

 

[mistafab]

One of my patients reported another doctor cause he was doing one of the most high end drug tests available, and her insurance was billed over $1000 per test. I believe it was gas chromatogry drug tests. She kept testing negative at my office, but at this guy's office she was always positive. She told me that the other doctor told her that there must be something wrong with his machine and kept doing it.

Given that it kept happening, and he allegedly wasn't fixing the machine I told her she should report this. Turned out the guy was running a scam making several hundreds of people do drug tests and the insurance would only pay for more testing if there was a positive test. Then as this guy was being investigated, several of his partners in crime went for immunity deals where they confessed they sent people to him and he gave them a slice of the pie, and intentionally put dirty samples in the machine so they knew the insurance would continue to allow for reimbursed tests. The guy is currently facing serious criminal charges, but still remains in practice. I'd put a link up to show this guy and the several local news articles, but the case is still pending so I don't want to take any HIPAA risk by putting his name up.

What a dirty, rotten bastard. Deserves to rot in prison.

He could destroy lives with false positive uds results, let alone the fraud.

 

[hamstergang]

I'd put a link up to show this guy and the several local news articles, but the case is still pending so I don't want to take any HIPAA risk by putting his name up.

If there is a news article that's available to the public, and he's not a patient of yours, then how could you possibly violate HIPAA by linking the article?

 

[dozitgetchahi]

That's not the statute people typically use for whistleblower cases. What happens is people file a "qui tam" suit under the False Claims act where the government is actually the plantiff but you're initiating the suit.

False Claims Act

www.law.cornell.edu

Exactly. And there have been multimillion dollar qui tam judgments in cases brought by whistleblowers.

 

[whopper]

What a dirty, rotten bastard. Deserves to rot in prison.

He could destroy lives with false positive uds results, let alone the fraud.

Next time I see you in person, I'll tell you who it is. (For everyone else Mistafab is in my area).

If there is a news article that's available to the public, and he's not a patient of yours, then how could you possibly violate HIPAA by linking the article?

I don't know if it was my patient alone or in chorus coincidentally with others that launched the the investigation. It's too direct to that patient if she was the one that caused this to happen.