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Can we do that?

Is it Fraud?
Is it Fraud?

I could not begin to recount all the times I have heard healthcare providers or their staff ask if they can bill Medicare or another insurance carrier for a non-covered service that they perform, but just code it as something else so that they can get paid.

It is little wonder that providers and staff might believe that this would be an acceptable practice when their colleagues tell them that they themselves do it, or their employer does it, or they heard it at a seminar, or in some cases even insurance representatives tell billing staff to do so!  (The latter scenario recently happened to me)

So let’s think about it….if Medicare receives a claim from a provider for G0283 (e-stim) but in actuality the patient was treated with infrared therapy (97026) which is a non-covered service, what is the provider telling the Medicare carrier?  He is telling the carrier that he treated the patient with electrical stimulation.  Is that truthful or is it fraudulent?

Please note the opening words of the Medicare Program Integrity Manual for Section 4.2.1

The most frequent kind of fraud arises from a false statement or misrepresentation made, or caused to be made, that is material to entitlement or payment under the Medicare program”

This section continues by listing many examples of Medicare fraud.  Among the fraudulent practices listed is:

  • Billing non-covered or non-chargeable services as covered items.

http://www.cms.hhs.gov/manuals/downloads/pim83c04.pdf

Naturally, healthcare providers often find it frustrating when they perform a service that benefits a patient, but the carrier has deemed it a non-covered service.  Providers deserve to be paid for the services they perform.

So what is the appropriate way to handle a situation such as this?  Tune in tomorrow for another edition of Can We do That?