Wiki Does this fall under false claims or any type of fair billing regulations

[TTcpc]

Hello,

I'm working on a project for fracture care billing and the question has come up whether a practice can legally/compliantly bill fracture care different ways for the same fracture care provided.

For example, we have two patients (Sally seeing Dr. Adams and Patient Billy seeing Dr. Jones) both come in with non-displaced distal radius fracture, both are placed in a short arm cast, and both are followed for 2-3 visits afterwards. The previous location (ER/UCC) did not bill fracture care but referred to ortho specialist for fracture care management/treatment. Can ortho specialist Dr. Adams bill Sally for itemized fracture care and Dr. Jones bill Billy for global fracture care? To clarify Dr. Adams and Dr. Jones are both in the same orthopedic specialty practice.

I'm asking as there are some ortho providers that are fine billing global fracture care; however, some are not. I'm trying to put together as much guidance as possible to make a stance for one vs the other - knowing that there will be times where maybe exceptions may need to be made/allowed.

If we allow the providers to bill differently for the same services, are we risking violating any statues? I'm thinking possibly treading into False Claims if to same insurance.

Any feedback/advice would be greatly appreciated!

 

[jkyles]

Hi there, off the top of my head and as a general guideline, if the overall billing pattern gives the impression that the practice is manipulating the way it bills to:
1. Charge federal/state programs (Medicare, Medicaid, TriCare) more than it does private payers.
2. Discriminate. For example, billing Medicare patients in a way that always results in greater out-of-pocket expense than for private payer patients.

Then you have a compliance risk. But again I think there has to be some sort of pattern.

 

[TTcpc]

Hi there, off the top of my head and as a general guideline, if the overall billing pattern gives the impression that the practice is manipulating the way it bills to:
1. Charge federal/state programs (Medicare, Medicaid, TriCare) more than it does private payers.
2. Discriminate. For example, billing Medicare patients in a way that always results in greater out-of-pocket expense than for private payer patients.

Then you have a compliance risk. But again I think there has to be some sort of pattern.

Thank you for responding! That's why I'm working on this project because we want to try to get everyone on the same page so that there would not be that suspicion there that charges were being manipulated for increased revenue/wRVUs.

I know some have expressed concern over patient liability when billing global vs itemized in the past and I don't want that to blur the lines of potentially being construed as unfairly billing one patient one way vs another way based on potential patient liability. I have sent information to them as well as creating a patient fracture care billing information sheet to help resolve all of the questions and reassure all that everyone will be billed fairly and assistance is available to those with high liabilities.

 

[jkyles]

Got it. I would say that when a practice has these kinds of concerns and is having these internal conversations, it is time to retain a health care attorney. A key reason is that that conversations around the issue will be protected by attorney/client privilege. (I'm not an attorney, so this isn't self-promotion )

Another key issue is if this turns out to be a compliance problem, a practice doesn't want to be in a position where it is apparent that it was aware of the problem, but either didn't fix it at all or did the wrong thing.