Insurance fraud?

[charley7702]

I'm a postdoctoral neuropsychology fellow in Arizona. In the reports we write, the supervisors name and post-docs names are supposed to be listed as co-authors (the postdocs write the entire report and the supervisor makes edits). I noticed several of the reports I had written being mailed out without my name on them. I started checking more and it was clear she was deleting the postdocs names off some (not all?) of the reports. She saves the final version of our reports to our shared folder with both names, whereas she is sending a different version to patients and the insurance company with her as the sole author. I'm frustrated because this is obviously unethical as we're the ones writing these reports and not receiving any credit, but I'm also wondering if this insurance fraud as well? This supervisor has a history of shady business practices in general so it's part of an ongoing trend that concerns me. There are 4 postdocs at this private practice and the supervisor appears to be taking credit for and billing for all of our work as if it's her own. I'm not comfortable asking her about why she's doing this in case I make a report for insurance fraud, she would definitely know it was me and I've seen her be pretty vindictive. Any insight is greatly appreciated!

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[WisNeuro]

Not enough information to tell you whether or not it's insurance fraud. You'd need to know what this person is billing for exactly to determine that. Insurance generally gives 0 ****s about names on a report, but they do care about things that are billed for that did not happen.

 

[charley7702]

I've seen the billing codes as well and she is billing for the report writing time we did (unlicensed practitioners) as if she did it (the licensed practitioner code)

 

[WisNeuro]

I've seen the billing codes as well and she is billing for the report writing time we did (unlicensed practitioners) as if she did it (the licensed practitioner code)

Be careful here. The time I spend integrating information, editing and re-writing reports, is billable. Generally, this will be shorter than my time from scratch, Though, I have been given reports that are so bad that I write my own report from scratch anyway. There are no codes for postdocs vs licensed practitioners, only add on codes specifying who performed services. Bottom line, if I was going to accuse someone of billing fraud, I'd want to make sure I had pretty good evidence.

 

[charley7702]

I totally understand what you're saying which is why I'm getting advice first before I think about doing anything. I mean the 96132/96131 codes. We actually do get the edited versions of our reports back (only one round of edits) and they're usually very minor edits (grammar/punctuation) which couldn't have taken her long to do. However, on the billing reports, she bills for 5 hours of "report writing" time using those codes and there's no way adding some commas to our reports is taking her 5 hours (I often get the final edited versions of the reports back from her within an hour or two, so it's definitely not taking her 5).

 

[WisNeuro]

the 132 code includes "integration of patient data, interpretation of standardized results and clinical data, clinical decision-making, treatment planning and report, and feedback to the patient, etc." I would only use that much time in very rare circumstances, but I am faster than most. Plenty of community providers routinely bill that much for 132/133. There may be something going on, but unless you can prove that she isn't using that time for those things, levying a felony charge on someone who can affect your career may not be the best course of action.

You'd have to see the billing procedures for the healthcare plan that is being billed. Know all of the exact billing codes and whether or not the multiple provider modifier was used, and the documentation on billing times of the provider. If you can do that, and it shows a very clear picture of fraud, go for it, otherwise, I'd leave it alone as a trainee.

 

[charley7702]

the 132 code includes "integration of patient data, interpretation of standardized results and clinical data, clinical decision-making, treatment planning and report, and feedback to the patient, etc." I would only use that much time in very rare circumstances, but I am faster than most. Plenty of community providers routinely bill that much for 132/133. There may be something going on, but unless you can prove that she isn't using that time for those things, levying a felony charge on someone who can affect your career may not be the best course of action.

You'd have to see the billing procedures for the healthcare plan that is being billed. Know all of the exact billing codes and whether or not the multiple provider modifier was used, and the documentation on billing times of the provider. If you can do that, and it shows a very clear picture of fraud, go for it, otherwise, I'd leave it alone as a trainee.

Alright, thank you for your advice

 

[Sanman]

It may be fraud and it may not be fraud. The bigger question here is if you do report this, is there any way in which there could be a positive outcome for you? I cannot see one.

 

[WisNeuro]

It may be fraud and it may not be fraud. The bigger question here is if you do report this, is there any way in which there could be a positive outcome for you? I cannot see one.

Additionally, you'll have to decide in your career which windmills you want to tilt at. I read reports from community providers on a weekly basis. Based on some of the billing documentation I see, I suspect some padding of hours in a good deal of it. Suspecting, and being able to prove it are very different things. As for board complaints, I've only made a couple of those in my career, in cases where I believed that real patient harm could occur due to the practice of the individual or practicing well out of scope. Choose your battles, because there are countless battles in healthcare, and very few are truly winnable.

 

[charley7702]

Additionally, you'll have to decide in your career which windmills you want to tilt at. I read reports from community providers on a weekly basis. Based on some of the billing documentation I see, I suspect some padding of hours in a good deal of it. Suspecting, and being able to prove it are very different things. As for board complaints, I've only made a couple of those in my career, in cases where I believed that real patient harm could occur due to the practice of the individual or practicing well out of scope. Choose your battles, because there are countless battles in healthcare, and very few are truly winnable.

The main issue at this point is I don't have any work samples with my name and supervisors signature on them to submit for job applications. I'm very frustrated because this is a small part of an ongoing issue with this postdoc and a supervisor who seems to be abusing the training system for cheap labor.

 

[WisNeuro]

The main issue at this point is I don't have any work samples with my name and supervisors signature on them to submit for job applications. I'm very frustrated because this is a small part of an ongoing issue with this postdoc and a supervisor who seems to be abusing the training system for cheap labor.

I've never had to submit a hand signed report for a job application. Vast majority of systems are using EMRs, so it's only a digital signature. Just use one of your finalized report drafts when asked. Or, if you want to make sure both names are on it, pick a few that you'd like to use, and bring them to your supervisor for advice and ask for a signed report in the off chance that someone wants a hand signed example. I wouldn't worry about it too much as long as you keep your own de-identified samples.

Is this a private practice? If so, could be some cheap labor. If it's a hospital system, not really. Trainees are a net loss for those of us in institutional settings.

 

[charley7702]

I've never had to submit a hand signed report for a job application. Vast majority of systems are using EMRs, so it's only a digital signature. Just use one of your finalized report drafts when asked. Or, if you want to make sure both names are on it, pick a few that you'd like to use, and bring them to your supervisor for advice and ask for a signed report in the off chance that someone wants a hand signed example. I wouldn't worry about it too much as long as you keep your own de-identified samples.

Is this a private practice? If so, could be some cheap labor. If it's a hospital system, not really. Trainees are a net loss for those of us in institutional settings.

I'll try that, thank you. Yes, it is a private practice. We're paid considerably less (i.e., nearly 10k per year less) than the institutional postdocs located in the same city. I accepted this position as my last option, but I'm thinking now it would've been better to wait another year and apply again.

 

[cara susanna]

I'm confused - isn't it typical to bill under the supervisor since you're practicing under their license?

 

[WisNeuro]

I'm confused - isn't it typical to bill under the supervisor since you're practicing under their license?

Yes, and there are nuances depending on Medicare vs. different insurance companies and how they view trainees and such. Generally though, whether you are using a tech or trainee for some of the work, there is a modifier that gets thrown on to the visit to signify multiple people involved in the same encounter. Creates a ton of billing issues with incompetent billing departments time and time again.

 

[DynamicDidactic]

She saves the final version of our reports to our shared folder with both names, whereas she is sending a different version to patients and the insurance company with her as the sole author.

How do you know this happens? And, do you know how often? I am curious whether this was a one time occurrence or you have evidence that indicates this happens often.

Your reports should be fine without signatures for job applications, so that isn't a concern.

I don't even understand why she would remove your name. She could still keep your name and bill with the same code. It isn't like she breaks down how much time each of you put in. So, it may be just a quirk from this person. I'd definitely want to better understand what is happening, how often, and if it is costing anyone more money.

 

[Unipsychler]

Perhaps I am an idiot, but I would approach a situation like this by saying to the supervisor that I've noticed some reports are saved with both names but submitted under the supervisor's name only, and asking in a curious/innocent tone why the procedure is like that. I would ask this as if I was assuming there is a perfectly good reason for it that hadn't occurred to me, in the context that as a post-doc I am here to learn the real-world procedures of practicing psychology. Tone is EVERYTHING here.

There's a couple reasons I'd do this:

• If there is a sound reason, I find out what it is without having accused a future job reference of fraud
• If it's a shady practice, I signal that it has been noticed, which may cause a correction, again without having accused a future job reference of fraud
• If I have my own separate logistical reasons to care about this (e.g., needing work samples), this opens the door to work around it. "Oh ok, so we need to file it this way for xyz insurance purposes, can I still get signed, deidentified copies as work samples for my private use?"

Edit to add: It may be as simple as, they know you need work samples so they have you save it with both names to make it very clear that you are free to take credit for it in your personal use. But there may be a separate reason that it goes under one name for clinical use (insurance, liability, having patients contact the practice directly after postdocs have moved on, etc.).

 

[deleted343839]

I would ask this as if I was assuming there is a perfectly good reason for it that hadn't occurred to me

Normally this is a reasonable approach but...

This supervisor has a history of shady business practices in general

I've seen her be pretty vindictive

...seems the OP has a sense that things are not always above-board with this supervisor. The question is what to do with this information, and to what end.

I don't see an issue with using the reports as work samples, especially since some of them still have both names. If that's your only concern, you can leave it there.

Think carefully before pursuing an insurance fraud claim. Yes, you can be a whistleblower, but what's your motivation for doing so? Who will benefit? Psychology is a small world, and threatening a person's livelihood is a risky move for a not yet licensed postdoc.

 

[pediatric_psydoc]

I would leave this alone. There is a lot to lose on your part. You have your work samples with your name on it and that is what you need for your career to move forward. I don’t see any good coming out of this for you if you approach her about this (regardless of tone).

 

[BuckeyeLove]

I think it's good that you're thinking through these issues. That being said, I would also let this one go. You're going to encounter this stuff in many shapes and forms long down the line. Not justifying it, but definitely not the hill to die on this early on when references are so very important, and you are not yet independently license.