Compliance is cheaper than a fraud investigation
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KOLOA, Hawaii — When an ophthalmology practice comes under investigation for fraud under the False Claims Act, ignorance is no excuse. Nor is laziness, according to a legal counselor who represents ophthalmology practices.
“Basically what the law says is, ‘You can’t submit claims to us that were fraudulent or false that you knew, or at least should have known, weren’t correct,’” Allison W. Shuren, MSN, JD, said at Hawaiian Eye 2020.
A “silly CPT error” can be costly, especially when repeated, she said. For instance, if the wrong CPT code is billed for a diagnostic test and the practice physician is reimbursed $70, then the penalty is three times the payment plus a penalty of up to $21,562. So, each time the $70 claim is falsely made, whether knowingly or unwittingly, each claim could cost up to $21,772.
“Compliance is always, always going to be cheaper,” she said.
Recent investigations involving ophthalmologists include medically unnecessary or unsupported services; upcoding services (exams and procedures); inappropriate use of ICD-10 codes; inappropriate use of modifiers (unbundling); comanagement issues; financial relationships with referrals sources; financial relationships with referral recipients; unlawful use of products; substandard services; false identification of physician who rendered services; routine waiver of copayments/deductibles; and falsifying medical records.
Notwithstanding the monetary costs of a fraud investigation, there are also human costs, including disruption to the practice, demoralization of the staff, the effect on public perception and personal stress.
“It is not worth it,” she said. “The government will take a case, even for small money returns, if they’re trying to make a point and trying to change behavior.” – by Patricia Nale, ELS
Reference:
Shuren A. Life under investigation. Presented at: Hawaiian Eye 2020; Jan. 18-24, 2020; Koloa, Hawaii.
Disclosure: Shuren reports she represents ophthalmology practices around the country.
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