The Chicago-area physician was charged with seven counts of healthcare fraud, three counts of making false statements and two counts of aggravated identity theft. Identity theft is punishable by a mandatory two-year sentence. Healthcare fraud is punishable by up to 10 years, and making false statements carries a maximum of five years.
Intentional or not, violating billing rules can lead to serious consequences. According to the U.S. Department of Health and Human Services, for example, it is illegal to submit claims for payment to Medicare or Medicaid that you know or should know are false or fraudulent. Filing false claims may result in fines of up to three times the programs’ loss plus $11,000 per claim filed, according to the HHS website. Remember: No specific intent to defraud is required for you to face fines.
Because mental health and substance abuse billing and reporting are notoriously complex, these processes abound with potential pitfalls for unintended fraud. Keep in mind these scenarios that could set you up for problems.
Reimbursement for certain CPT and Revenue codes.
Keeping track of which payors reimburse which CPT and Revenue codes is challenging, especially when you’re dealing with multiple insurance companies. For example, many companies don’t reimburse for couples counseling. If you change the couples counseling code to that for individual therapy to receive reimbursement on that claim, you’ve committed fraud.
Reimbursement for treating certain diagnoses.
It can be difficult to keep track of which payors disallow which diagnoses. Clinics can be unintentionally fraudulent when they change the diagnosis to an allowed DSM just for the purpose of having claims reimbursed.
Billing outside the standard clinic fee schedule.
Understanding at what rate your clinic will be reimbursed can be confusing, particularly when dealing with out-of-network services. Clinics that work with both in-network and out-of-network payors must maintain proof that they bill a consistent rate. Artificially increasing the charged amount on out-of- network claims is fraud.
Even if your goal is to help your client find the bill more affordable, charging less than the standard fee without an established fee schedule is fraud. Don’t automatically waive clients’ co-payments. Make a reasonable attempt to collect the co-payments, and document the rationale and the process by which you forgave unpaid balances. Consider sliding scale fees to make payments more affordable. If you do offer a sliding scale fee, make sure that you bill the insurance company at the sliding scale fee, not at your full fee.
ClinicTracker offers features that help you avoid scenarios that may lead to unintentional fraud. The Appointment Save Restriction module prevents you from performing appointments for which you won’t be reimbursed.
ClinicTracker allows you to manage fee schedules in a number of audit-compatible ways. You can set default service prices, which shows your standard fee schedule for non-contracted payors. Payor-specific fee schedules allow you to track contracted reimbursement rates.
ClinicTracker also allows you to enter reduced fee schedules for self-pay patients based on the client’s income and family size. This feature lets you automatically bill qualified clients a lower service fee, while maintaining appropriate records to show why you made the change.
We know it’s challenging to keep track of numerous complicated billing arrangements. Mistakes can happen, but violating billing rules can be costly. Let ClinicTracker customize your billing workflow to avoid unintended fraud. You can also use our Billing Service to ensure a higher level of oversight of your billing practices.
ClinicTracker is a robust, future-proof mental health and substance abuse EHR. Michael Gordon, a respected clinical psychologist, and Joshua Gordon, an award-winning software engineer, founded the company in 2000. ClinicTracker EHRs powerful software empowers your agency to succeed. ClinicTracker will automate many of your clinic routines, boost staff productivity, increase billing efficiency, and provide the tools you need to manage your clinic effectively. While mental health and substance abuse agencies are our main focus, our software is compatible with foster care agencies, social services, equine assisted therapy, university clinics, academic counseling, family counseling services, and eating disorder clinics.