Medical Billing Horror Stories

Health care fraud is on the rise. As with any field, criminals try to cheat the
system, and the government is cracking down to prevent it. Fraud costs taxpayers
millions of dollars. My goal is to help doctors identify what their peers have done
right and wrong. I have provided case studies on what doctors are doing in their
billing practices, and also, I have included some red flags and audit triggers so
doctors can avoid billing incorrectly.
This book was not initially intended as a medical legal thriller, but what
you are about to read are true accounts of medical billing horror stories that
have been ripped from the headlines. If you want to hear what happened to the
nurse who posted a narrative and a patient’s confidential x-ray on Facebook or a
group of doctors who marketed patients in a rent-a-patient scam and performed
unnecessary operations, then this book is for you.

The cases presented within these pages are true stories of medical professionals:
Some are about providers just like you. Many doctors are just trying to
navigate the maze of the medical billing process. Without a clear understanding
of coding requirements, some thought that if they only bill just 99213’s, they
could stay under the radar. What they didn’t expect is that by doing this and not
varying their coding appropriately, they were raising red flags about their billing
practices which led to them being audited by Medicare.
Within these pages are case studies of providers that agreed to split a fee
with another provider, or entering into a business agreement with another doctor
or a hospital. They thought, “Well, everyone is doing it.” What they, too, didn’t
expect is that the Office of Inspector General (OIG) eventually investigated them.
Also, there are case studies about providers who have committed fraud, and
thought, “Well I won’t get caught.” However, they were investigated and the FBI
convicted many of fraud.

The case studies have all been grouped by specialty to simplify and illustrate
what your peers have done. Some of these cases, as a result of audit findings,
resulted in doctors having significant financial impact such as having to repay
Medical Billing Horror Stories

Medicare or other 3rd party payors. Some doctors also had significant fines in
addition to refunding money back to Medicare and some cases where doctors
were faced with criminal and civil penalties including incarceration.
Doctors have a legal obligation to not only treat their patients appropriately
and with medical necessity but also to comply with the health laws and the
authorities who oversee the laws, including but not limited to: HIPPA, Department
of Health and Human Services, Office of Civil Rights, Centers for Medicare and
Medicaid Services, and the Department of Justice.

Submitting claims to a third party for reimbursement exposes doctors to
a litany of scrutiny. Doctors and other healthcare providers need to read these
cases in order to learn the ins and outs of medical billing. Specifically, they
must understand how to avoid an audit, prosecution, and the civil and potential
criminal penalties for violating the law.

Due to the complexities of medical billing, the insurance marketplace and
constant changes to both reimbursement and insurance coverage, providers often
do not know how much they are going to be paid for care.
Doctors must understand what to do in order to receive timely and accurate
payment for their care, while avoiding submitting claims that may result in audits
or fraud alerts. If doctors learn to navigate the billing maze, they will be able to
focus on providing quality medical care for their patients.
Compiled in this book are some of the 130,000 separate Medicare regulations
and policies, and I have explained them in simple terms to assist in navigating the
healthcare maze.

This book was current at the time it was written; however, Medicare policy
changes frequently. Links to the source documents, with references, can be found
in the back of the book.

In my years as a healthcare consultant, my zeal to communicate these Do’s
and Don’ts of practice management to doctor’s has made for some very heated
discussions. My knowledge about billing rules and regulations and Medicare
Guidelines has not always made me popular with providers. To be clear, I didn’t
create the laws or rules so please don’t shoot the messenger.
As a healthcare consultant, an expert in reimbursement, and the current
president of a successful medical billing service, I thought I had seen it all.