The “F” Word

Featured coffee – Sticky Buns Flavored Coffee

I’ve noticed on social media sites, that coders often advise others to report issues as fraud.  Let’s review the “f-word.”

According to the Office of the Inspector General (OIG):

“Fraud is defined as the wrongful or criminal deception intended to result in financial or personal gain. Fraud includes false representation of fact, making false statements, or by concealment of information.

Waste is defined as the thoughtless or careless expenditure, mismanagement, or abuse of resources to the detriment (or potential detriment) of the U.S. government. Waste also includes incurring unnecessary costs resulting from inefficient or ineffective practices, systems, or controls.

Abuse is defined as excessive or improper use of a thing, or to use something in a manner contrary to the natural or legal rules for its use. Abuse can occur in financial or non-financial settings.”

We learned in compliance training that healthcare fraud is the “intentional deception or misrepresentation that results in unauthorized payments.”

Some of the most common types of healthcare fraud are:

• Submitting claims for services not performed
• Billing for more expensive services (upcoding)
• Performing medically unnecessary services with the intent to receive payment
• Reporting false diagnoses to support services

The OIG provides free compliance training through its website.  Click here to navigate directly to the relevant page on the OIG website.

I managed a coding contract and was responsible for assigning coders to various hospital-based clinics.

Part of each coder’s responsibility was to provide physician education when issues were identified.  One coder scheduled a provider feedback session after only coding the first day of notes.  She did not review her findings with me or inform me that she scheduled a meeting with the physicians.

After her meeting, the department chief requested a meeting with me.  The coder accused the physicians of committing fraud.  Yes, she used the “F word”! She claimed that the providers were up coding the E/M levels.   As a Certified Professional Compliance Officer ^TM, I recognized the seriousness of the accusation.  We don’t conclude that without sufficient evidence, and even then, we’re cautious of using the word fraud.  I assured the department chief that I would review the records and meet with the providers.

I met with the coder, and she was convinced the providers were committing fraud.  I explained the seriousness of her accusation and asked her to provide evidence of fraud.  The providers assigned codes on their notes.  The coder was responsible for validating the codes, making necessary corrections, and providing coding and documentation education to the providers.

I gave her the definition of fraud and explained that to even raise the concern, she would have to confirm that the providers knowingly and willfully up coded the services.   She was not able to show proof because the providers did not possess coding knowledge.  It was her responsibility to validate the codes, so they did not act in ‘deliberate ignorance or reckless disregard of the truth or falsity of the information’ as defined by the False Claims Act [31 U.S.C. § § 3729-3733].

 

Certified Professional Compliance Officer ^TM   is a trademark of AAPC.

 

Do Not Change the Codes

Featured coffee – Cool Café Blues® flavored coffee

The responsibility of a medical coder varies from translating the provider’s documentation to codes to entering the codes selected by the provider into the billing system.  There are many job descriptions for all of the responsibilities in between. 

In a previous blog, I wrote that if you are only entering the provider’s codes, you are not a coder, you are a charge entry clerk. Some coders validate the provider’s codes by reviewing the documentation, checking for bundling edits, making coding corrections, linking diagnoses, and providing coding feedback to the provider, but whatever the role of the coder, ultimately, the provider is responsible for the claims submitted for payment. 

I met with a physician to review his audit findings. I knew he coded his own services, and his coder was responsible for entering the charges in the billing system.  He failed the audit because the E/M levels were over-coded.  Surprisingly, the physician agreed with my findings.

He called the coder into the conference room, and she said she changed the E/M levels because she felt that he did more work than he documented, and he should be paid more.

When she said it, the only thing in my head was, “I did not hear this, she did not just say this, what am I supposed to do with this?” The physician and I looked at each other, and he exploded!  He yelled at her that he could lose his practice because of inaccurate claims.

I explained to her that she put him in a precarious position with the payers and that we had to correct it immediately. I went into compliance mode. I outlined the corrective actions that needed to be done, all the way to refunds, and I followed up the meeting with written recommendations.

This simple probe audit became weeks of compliance work, and the coder was replaced with a data entry clerk.

Audit the Auditor

Featured Coffee – Maple Bacon Morning Coffee

 

I worked as part of an auditing team and noticed that another auditor was changing my findings. It was annoying that she was auditing me and I disagreed with the changes she made.  

The Project Manager called me with concerns raised by the other auditor and asked if I would meet with him and the other auditor. The Project Manager set up a conference call to review the other auditor’s findings. 

On each one, I was able to defend my findings based on coding and payer specific guidelines. Her conclusions were based upon incorrect interpretations of the guidelines and her personal opinions. 

I could tell she had given up long before we finished. The coding manager was quiet during our discussion. The other auditor apologized and told me that I should teach coding. Hmmm…