Indicators of Medical Billing Fraud

Transcription

1 DOCUMENT 3 Claimant, Julian Carol St 17 XX RECEIVED BY INSURCO Rock City IA IA Insurco XX S43 409A R Shoulder S/S S13 4XXA S23 8XXA Cervical S/S Thoracic S/S XX XX c1234 E. Harrington Physician 8/2/XX Rock City Clinic 41 Medical Plaza Rock City Rock City Clinic 41 Medical Plaza Rock City

2 Indicators of Medical Billing Fraud Most claims are legitimate, but some are fraudulent. Therefore, it is appropriate for the claim handler to review all claims for possible fraud. Determining the "fraud probability" of any claim is facilitated when the claim handler is familiar with various fraud indicators. These indicators should help isolate those claims which merit closer scrutiny. No one indicator by itself is necessarily suspicious. Even the presence of several indicators, while suggestive of possible fraud, does not mean that fraud has been committed. Indicators of possible fraud are "red flags" only, not actual evidence. Some claims, although suspicious, may have to be paid for lack of conclusive evidence of fraud. However, they should be referred to your Special Investigations Unit for further review and/or submitted as questionable claims to the ISO Database. As many of these indicators are specific to the medical bill, they should be used in conjunction with NICB s Indicators of Casualty Fraud. General Indicators 1. Accident. Vehicle damage is minor but medical claims are etensive. 2. Accident. Vehicle driven by claimant is an old clunker with minimal coverage. 3. Accident. Three or more occupants in the claimant or struck vehicle all report similar injuries. 4. Attorney is listed as the insurer on the medical bill. 5. Attorney representation is obtained immediately (within 48 hours). 6. Attorney. The same attorney appears in all BI/WC cases involving a particular medical provider. 7. Bills are submitted by billing or medical finance companies and not the provider. 8. Bills are submitted months after treatment is rendered. 9. Bills are submitted without appropriate supporting documentation, e.g., PT worksheets or diagnostic imaging reports. 10. Bills are templates or prepared forms that do not document the actual facts of a patient s case. 11. Bills are submitted in bulk just before the time deadline to reduce amount of time the insurance carrier has to validate and investigate the claim circumstances. 12. Bills for E&M provide little or no detail but the CPT code billed reflects an office visit of high compleity, comprehensive history/eam, etc. 13. Bills. A summary of medical bills is submitted without dates and descriptions of office visits. 14. Bills. Amounts billed for are much more than other providers (of the same specialty) charge. 15. Bills. A physician bills out of multiple offices on one day. (Treatment time is more than possible for one day.) 16. Bills. The physician s bill and report, regardless of the varying accident circumstances, is always the same. 17. Bills. Provider bills for treatment that was not provided. 18. Bills. Provider bills for medical tests or evaluations that were not conducted. 19. Bills. Provider bills for medical supplies that were not used. 20. Bills. Provider bills for office visits that were not made. 21. Bills. Provider bills cancellation charges for office visits that were not originally scheduled. Indicators of Medical Billing Fraud v6 7/7/10 Page 1

3 22. Bills. Provider bills a referral fee for medical services that were never rendered. 23. Contradictions are revealed by comparing information (e.g. diagnosis codes versus treatment codes, treatment billed for versus treatment described by patient, treatment plan versus injury, DME billed for versus DME received by patient, type or quantity of diagnostic tests versus injury and/or standards of care, unbundled CPT codes versus comprehensive CPT codes, etc.). 24. DME billed for multiple patients is the same. 25. DME. TENS unit charges are very epensive (often billing for more advanced units without attempting treatment with basic, less epensive units first). 26. DME. TENS unit charges include frequently billed supplies such as electrodes and batteries. (Charges may also be ecessive.) 27. Injury is not shown as auto accident related or workplace related on the 1500 bill. 28. Injuries are all subjectively diagnosed, such as soft-tissue injuries. 29. Injury progression is atypical and seems to require etended treatment (often etending beyond estimated discharge date ). 30. Injury type is not consistent with the circumstances of the accident. 31. Injury. Medical condition treated as result of accident is pre-eisting (usually determined from eamining patient s medical records). 32. Kickbacks. Evidence eists of payments/commissions from a test provider to the ordering practitioner. 33. Patient cannot describe the physical aspects of items appearing on the bill (e.g. ROM test eercises). 34. Patient indicates the provider listed on the bill is not the same person providing treatment. 35. Patient is quoted a treatment price but the bill shows a much higher amount. 36. Patient is unable to describe the doctor or office location. 37. Patient refutes charges. 38. Patient s residence is not near treatment facility. 39. Provider bills for an eamination and treatment when in fact no treatment was provided. 40. Providers. Multiple providers in one office all treat the patient on the same day. 41. Reports. Boilerplate and matching reports from providers are present in claim file during review. 42. Treatment is ended when the policy s monetary limits are reached. Indicators in Diagnosis 1. Advanced diagnostic testing (X-rays, EMG testing, MRIs, etc.) occurs in the first few weeks of treatment, particularly in a low-impact accident. 2. Bills for diagnostic imaging are submitted without supporting documentation such as reports. 3. Comparison across patients. A test or series of diagnostic imaging tests is given to all patients at a clinic or medical office regardless of injury. 4. Comparison diagnostic tests are ordered by provider (e.g., performing a diagnostic test on an uninjured joint so the resulted can be compared to the diagnostic test results from the injured joint). 5. Diagnosis in the bill is not supported by other documentation. 6. Diagnostic imaging is not consistent with the nature of the injury or treatment. 7. Diagnostic imaging is performed often and early in treatment. 8. Diagnostic imaging is performed on several separate visits rather than one. Indicators of Medical Billing Fraud v6 7/7/10 Page 2

4 9. Diagnostic testing is billed repeatedly without a report of a worsening condition in objective finding or a report of a new injury. 10. EKGs are administered to patients with no complaints or conditions. 11. Insured questions the amount of diagnostic imaging tests ordered. 12. Location. Discrepancies eist between the locations of diagnostic imaging testing (and other types of tests) and the person interpreting the test. 13. Multiple diagnoses are indicated on bill. 14. Multiple diagnostic procedures are billed with separate CPT codes when there is a CPT code that includes all of the billed procedures. 15. Patient does not know the result of the diagnostic test(s). 16. Patient s account of diagnosis process is inconsistent with bill. 17. Progress. Ultrasound is used repeatedly to check on treatment progress; or, -rays, nerve conduction tests, or spinal videofluoroscopy are used repeatedly during treatment. 18. Range of motion (ROM) tests are conducted frequently. (This could be unbundling, as often ROM tests are included in the initial or follow up eams.) 19. Specialized equipment is required for diagnosis but the injured person cannot describe the equipment or procedure. 20. Surface EMGs (SEMG), billing for. Indicators in Treatment 1. Accident date. Treatment begins prior to the accident date. 2. Billing. Treatment etends for a lengthy period without interim bills. 3. Claimant. Treatment requires specialized equipment, but the injured person cannot describe the equipment or procedure. 4. Comparison across patients. Treatment prescribed for the various injuries resulting from differing accidents is always the same in terms of duration and type of therapy. 5. CPT codes are billed for the treatment which are usually not associated with the particular diagnosis/icd-9 code. 6. Dates of treatment on the medical bills indicate routine treatment is being provided on Sundays or holidays. 7. Delay in treatment on the bill indicate that the start of treatment is delayed by more than four weeks from the loss date. 8. Durable medical equipment (DME) bill shows charges for equipment not in the doctor s order or patient s receipt. 9. Durable medical equipment (DME) bill shows markups for equipment in ecess of your state s standards for such markups. 10. Durable medical equipment (DME) given to all claimants is the same regardless of diagnosis. 11. Durable medical equipment is dispensed without instructions for use. 12. Emergency services are billed by providers. (Providers say they provided services on a day when their office is routinely closed.) 13. Injury. Minor injury results in a network of treatment providers, diagnostic procedures, and treatments. (This often involves multiple claims with the attorney.) Indicators of Medical Billing Fraud v6 7/7/10 Page 3

5 14. Pain management protocol is not modified (treatment is continued) even when not effective. 15. Passive treatment modalities are used eclusively without encouraging use of a home program of eercises/activity. 16. Patient is seen multiple days in a row. (Provider may be attempting to disguise unbundling to pass audits.) 17. Patients who are members of the same family are treated on different days. 18. Patient s account of the treatment process is inconsistent with bill. 19. Patients all receive the same treatment plan and the doctor s initial eam reports are fill in the blank boilerplate reports. 20. Patients in one claim all receive the same treatment (same treatment dates, same treatments, same eamination/progress reports, etc.). 21. Pharmaceutical bills indicate repackaging or compounding on the part of the treating provider. 22. Procedures. Multiple treatment procedures are billed using separate CPT codes when there is a CPT code that includes all of the billed procedures. 23. Progress. Chiropractic treatment etends beyond visits for simple soft tissue injuries. 24. Progress. No referral is made to another specialist for evaluation when no progress is made after four weeks of treatment. 25. Progress. The frequency or number of therapy modalities does not decrease after four weeks of treatment. 26. Progress. Treatment is etended, without re-evaluation or outcome assessment. 27. Progress. The treatment plan does not change over time (especially if additional diagnostic tests have been done). 28. Progress. Doctor s notes contain no indication of checking the patient s treatment progress/improvement of symptoms. 29. Progress. Provider repeatedly uses -rays, ultrasounds, nerve conduction tests, or spinal video fluoroscopy to check treatment progress. 30. Provider. Medical treatment is given by receptionists or other non-medical personnel. 31. Provider. Patients are seen only by a chiropractor on the initial visit, yet proceed to get treatment from all modalities (acupuncturist, physical therapist, neurologist, etc.) before seeing a medical doctor. 32. Rehabilitation or physical therapy bills are not supported by worksheets showing the who, what, when, where, effectiveness of the treatment program, and/or modification if not successful. 33. Reports for initial eams, follow-ups, consultations, etc. provide little or no detail, but the CPT code billed reflects high compleity, comprehensive history/eam, etc. 34. Standards of care. Treatment is not consistent with usual standards of care. 35. Time billed. Multiple time-based modalities are billed for the same treatment session, resulting in the patient being in treatment for two or more hours (including acupuncture and massage). 36. Time billed. Office visits etend daily for more than five consecutive days or continue for more than one week. 37. Time billed. Treatment shows more than three therapy modalities in a single treatment session. 38. Time billed. Treatment time billed by a provider is more than is possible in one day. 39. Time-dependent procedures don t match what was billed (more treatments than possible in a 24 hour day). Indicators of Medical Billing Fraud v6 7/7/10 Page 4

6 Indicators Concerning Specific CPT Codes See the CPT Reference Guide to find indicators for particular CPT codes listed in CPT code order. 1. Acupuncture, first 15 minutes (97810 or 97813), billed numerous times per visit. 2. Acupuncture, subsequent 15 minutes (97811 or 97814), billed more than twice per visit. 3. Biofeedback (90901) is performed on all of a provider s patients. 4. Chiropractic manipulation ( ) routinely billed in conjunction with an E&M visit without documentation of a separate office visit where treatment was required beyond normal pre- and postmanipulation assessment (should be billed with a -25 modifier). 5. Community reintegration training (97537) billed repeatedly. 6. Consultation ( ) billed for own patient. 7. Davis series (72052) charge with fewer than seven images or reports. 8. Digital analysis of electroencephalogram (97957), appearance on bill. 9. E&M, prolonged services (99358), appearance on bill. 10. E&M codes, comple/severe (9924-5), billed for every visit until discharge. 11. E&M codes, comple/severe (9924-5), billed for problem of relatively low severity. 12. E&M, new patient ( ), billed every visit. 13. E&M, new patient ( ), billed for by provider in the same medical group where the patient has previously received treatment within the past three years. 14. Electric stim (97014) with modifier ESI (62310 or 62311) billed more than three times in one calendar year. 16. ESI ( or 62311), separate charge for drug and supplies (e.g. syringes, gloves, alcohol, etc.) Interpretation hours (90887), billed with little detail in report. 18. Manual therapy (97140), routine appearance of charge. 19. Mechanized traction (97012), routine appearance of charge 20. Modifier -51, routine appearance on bills. 21. Modifier -52, routine appearance on bills Modifiers, frequent use of. (Modifiers indicate treatment outside of the norm. Most treatment should fall with the normal parameters). 23. MUA (22505, manipulation under anesthesia) billed by a chiropractor (may also bill for assistant surgeons and standby assistant). 24. MUA (22505, manipulation under anesthesia) performed early in treatment 25. MUA (22505, manipulation under anesthesia) in conjunction with and Muscle testing (95831) billed for each muscle rather than each etremity. 27. Muscle testing (95831) billed in conjunction with E&M codes, eg Needle EMG (95860, single etremity) multiple times per visit. 29. Needle EMG (95864), all four etremities (without justification documentation). 30. Nerve conduction tests (95900, 95903) show the same results across patients. 31. Nerve conduction (95900 and 95903) on the same bill for the same nerve (95903 includes 95900). 32. Nerve conduction tests (95900, 95903) billed multiple times for the same nerve. Indicators of Medical Billing Fraud v6 7/7/10 Page 5

7 33. Neuromuscular re-education (97112) billed in connection with a soft-tissue injury without nerve damage. 34. PDD (62287,Percutaneous disk decompression), appearance on bill. 35. Psychological test interpretation time (90887) is billed along with administration time (96101) without supporting documentation. 36. Psychological testing (96101) report is without detail. 37. Range of motion testing (95832) is billed for each muscle tested. 38. Range of motion testing (95832) is billed in conjunction with Range of motion testing (95832) is billed in conjunction with E&M, eg Range of motion testing (95832), frequent. 41. Self-care/home management training (97535) billed repeatedly. 42. Subcortical/cortical mapping (95961, 95962), appearance on bill. 43. Therapeutic activities (97530) billed in conjunction with Therapeutic procedure with -51 modifier. 45. Unlisted modality (97039), appearance of charge. 46. Unlisted procedure 97139, appearance of charge. 47. Unlisted rehab (97799), appearance of charge. 48. Unlisted codes (ending in 99). All such codes should be reviewed for the potential of incorrect coding, fraud, and/or lack of clinical value. Indicators of Medical Billing Fraud v6 7/7/10 Page 6