Reporting double billing and fraud

[Iamnew2]

Looking for some assistance here. So as I have posted in the past, I was a med director at an IRF. There was a Medicine team there as well, and they were shady to say the least. One of the issues I have come across is that they would bill for services they didn't provide. For example, they would bill discharge codes (99239) when I would do all the discharge paperwork, dc summary, med recs, etc. This is outrageous. Initially I thought perhaps it was a single event but clearly it is a pattern. Not only are they billing for services they don't provide, but they are also depriving me of money for services I did provide.

Anyone have any information regarding how to report this to care source? Thanks!

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[j4pac]

Looking for some assistance here. So as I have posted in the past, I was a med director at an IRF. There was a Medicine team there as well, and they were shady to say the least. One of the issues I have come across is that they would bill for services they didn't provide. For example, they would bill discharge codes (99239) when I would do all the discharge paperwork, dc summary, med recs, etc. This is outrageous. Initially I thought perhaps it was a single event but clearly it is a pattern. Not only are they billing for services they don't provide, but they are also depriving me of money for services I did provide.

Anyone have any information regarding how to report this to care source? Thanks!

Did you ever point this out to them? There is a chance that it’s not malicious and they simply don’t know how to bill

 

[Iamnew2]

Did you ever point this out to them? There is a chance that it’s not malicious and they simply don’t know how to bill

This has been done repeatedly. It's not a once off instance. On some days that they have charged for a 99239, they haven't even put in a note. They also pretend to be PM&R physicians when they are not.

 

[j4pac]

This has been done repeatedly. It's not a once off instance. On some days that they have charged for a 99239, they haven't even put in a note. They also pretend to be PM&R physicians when they are not.

Well, then I wouldn’t have any regret reporting them for fraud.

I’d just be aware that your billing will also likely be scrutinized

 

[DMBandFan86]

My impression is that insurance will only pay for 1 discharge per day. So either they paid one of you, or denied both.

If you believe they had intent and purposefully didn't bill appropriately, then I believe you have an obligation to report. As the above poster, likely your billing will also be audited/scrutinized. But you can also get into quite a bit of trouble for not reporting, if it was ever discovered that you knew and didn't report it.

 

[Iamnew2]

My impression is that insurance will only pay for 1 discharge per day. So either they paid one of you, or denied both.

If you believe they had intent and purposefully didn't bill appropriately, then I believe you have an obligation to report. As the above poster, likely your billing will also be audited/scrutinized. But you can also get into quite a bit of trouble for not reporting, if it was ever discovered that you knew and didn't report it.

No the other team is a consulting/medicine team so I did all the discharges med rec etc etc. so I billed for that as 99239. I guess the medicine team also billed for some reason and this has happened before in multiple instances and is not an accidental bill as could at times happen. In this one instance they didn’t even put a note or see the patient. These are physicians who would also clone documentation daily and literally copy and paste the exact same note for days on end.

 

[RangerBob]

My impression is that insurance will only pay for 1 discharge per day. So either they paid one of you, or denied both.

If you believe they had intent and purposefully didn't bill appropriately, then I believe you have an obligation to report. As the above poster, likely your billing will also be audited/scrutinized. But you can also get into quite a bit of trouble for not reporting, if it was ever discovered that you knew and didn't report it.

Agree with the above. Only one doc can use discharge code. Not sure how insurance prioritizes things when two submit it.

OP-if your notes and billing are solid, and the internists really were acting fraudulently + depriving you of earnings, then I agree you shouldn't regret reporting them. Just be prepared for some hassle/headache Medicare look at your notes as well. I believe you actually get paid half of whatever Medicare recoups from the group. So if it's a widespread issue with the group and not just on rehab, that could add up to a fair amount. And could easily put the group out of business...

So just be aware you're not just burning the bridge with this old unit/hospitalists, you're blowing up the debris once it falls. But as stated above, you sort of are obligated to report something this intentional if you're aware of what's going on. And not reporting could get you in more trouble.

 

[Iamnew2]

Agree with the above. Only one doc can use discharge code. Not sure how insurance prioritizes things when two submit it.

OP-if your notes and billing are solid, and the internists really were acting fraudulently + depriving you of earnings, then I agree you shouldn't regret reporting them. Just be prepared for some hassle/headache Medicare look at your notes as well. I believe you actually get paid half of whatever Medicare recoups from the group. So if it's a widespread issue with the group and not just on rehab, that could add up to a fair amount. And could easily put the group out of business...

So just be aware you're not just burning the bridge with this old unit/hospitalists, you're blowing up the debris once it falls. But as stated above, you sort of are obligated to report something this intentional if you're aware of what's going on. And not reporting could get you in more trouble.

Yeah initially I kinda thought what j4pac mentioned maybe it was an honest mistake it happens. But repeatedly and with no notes? This is not an accidental thing. This is the same group that pretends to be PM&R but are only Family/Medicine doctors and write notes under PM&R. I assume that if they are doing this here where I was, they are doing it elsewhere. Honest mistakes don't tend to continue in my opinion.

 

[BSM_OTO]

Yeah initially I kinda thought what j4pac mentioned maybe it was an honest mistake it happens. But repeatedly and with no notes? This is not an accidental thing. This is the same group that pretends to be PM&R but are only Family/Medicine doctors and write notes under PM&R. I assume that if they are doing this here where I was, they are doing it elsewhere. Honest mistakes don't tend to continue in my opinion.

So they're financially benefitting off of acting significantly more qualified than they are, taking money out of your pocket.. sounds like mid-level behavior. and they're committing fraud.

Report.

Ignoring stuff like this is why certain healthcare professionals get taken advantage of and less qualified individuals in healthcare take their money.

 

[hamstergang]

Yeah initially I kinda thought what j4pac mentioned maybe it was an honest mistake it happens. But repeatedly and with no notes? This is not an accidental thing. This is the same group that pretends to be PM&R but are only Family/Medicine doctors and write notes under PM&R. I assume that if they are doing this here where I was, they are doing it elsewhere. Honest mistakes don't tend to continue in my opinion.

It could still be an honest mistake in that they don't understand how to bill properly, not that it's an accidental misclick.

 

[Iamnew2]

So they're financially benefitting off of acting significantly more qualified than they are, taking money out of your pocket.. sounds like mid-level behavior. and they're committing fraud.

Report.

Ignoring stuff like this is why certain healthcare professionals get taken advantage of and less qualified individuals in healthcare take their money.

Yep, I just have to look at all the claims this has happened

It could still be an honest mistake in that they don't understand how to bill properly, not that it's an accidental misclick.

Billing for patients they don’t see?

 

[forchinet121]

Yeah initially I kinda thought what j4pac mentioned maybe it was an honest mistake it happens. But repeatedly and with no notes? This is not an accidental thing. This is the same group that pretends to be PM&R but are only Family/Medicine doctors and write notes under PM&R. I assume that if they are doing this here where I was, they are doing it elsewhere. Honest mistakes don't tend to continue in my opinion.

Did you bring this up to them? The first step is to talk to the physician and see what they have to say before reporting them right?

 

[Iamnew2]

Did you bring this up to them? The first step is to talk to the physician and see what they have to say before reporting them right?

It’s not my duty to police physicians much less seasoned physicians. I don’t think I have to tell other doctors to not bill for patients they didn’t see

 

[j4pac]

It’s not my duty to police physicians much less seasoned physicians. I don’t think I have to tell other doctors to not bill for patients they didn’t see

You don’t have to do anything. It is completely your choice. If you think that these guys are intentionally commuting fraud, then report them. You don’t need our blessing and you seem pretty intent on doing so. My only concern is that just about any of us can be committing insurance fraud at any given time with how difficult it is to bill. If you report them, you better be ready for your encounters to be scrutinized…as an investigation can trickle down toward you. If you are ok with that and to burn bridges at your current group…then report them. But I honestly would be looking for another employer (unless you already have, sorry I don’t remember the details of your case).

 

[forchinet121]

You don’t have to do anything. It is completely your choice. If you think that these guys are intentionally commuting fraud, then report them. You don’t need our blessing and you seem pretty intent on doing so. My only concern is that just about any of us can be committing insurance fraud at any given time with how difficult it is to bill. If you report them, you better be ready for your encounters to be scrutinized…as an investigation can trickle down toward you. If you are ok with that and to burn bridges at your current group…then report them. But I honestly would be looking for another employer (unless you already have, sorry I don’t remember the details of your case).

Exactly this

 

[lejeunesage]

You don’t have to do anything. It is completely your choice. If you think that these guys are intentionally commuting fraud, then report them. You don’t need our blessing and you seem pretty intent on doing so. My only concern is that just about any of us can be committing insurance fraud at any given time with how difficult it is to bill. If you report them, you better be ready for your encounters to be scrutinized…as an investigation can trickle down toward you. If you are ok with that and to burn bridges at your current group…then report them. But I honestly would be looking for another employer (unless you already have, sorry I don’t remember the details of your case).

I think she mentioned that she's already left that place.