Fraud, Waste and Abuse in Mental Health Billing
The only legal way to be paid for a service is to bill using the correct CPT code. You must document that the level of service claimed was medically necessary and delivered. Fraud occurs when a person knowingly does something wrong that benefits them or another person. Abuse (and Waste) occurs when the use of health care services or funds result in unnecessary cost. Waste and abuse are not necessarily intentional. So let’s discuss fraud, waste, and abuse in mental health billing.
Kennedy-Kassebaum (Title II of HIPAA, 1996)
- Added “knowingly and willingly” standard to false claims legislation. Before 1996, physicians could be accused of violating the law if they simply made a mistake. Now, the standard is “knowingly and willingly,” BUT ignorance of coding rules is NOT an acceptable explanation for repeated coding errors.
- Made “falsifying” a private claim a federal offense like falsifying a Medicare/Medicaid claim.
- Added 700 investigators to the Inspector General’s office at CMS.
- The physician is responsible (and liable) for all coding done in that physician’s name. The physician is responsible for appropriate documentation of services even if the patient or physician’s employer submits the bill to an insurance company.
Related Article: APPEALING DENIALS FOR MENTAL HEALTH
False Claims
Billing for services not provided (False Claims Act (FCA) 1986).
Upcoding
Reporting a higher-level service or procedure than one that is performed or is medically necessary. For example, reporting the psychotherapy to add on code for less than 16 minutes of psychotherapy. Coding 99214 while documentation and medical necessity support a lower level of service.
Code edits
Billing codes that do not belong together (Correct Coding Initiative – CCI). Most edits involve surgical procedures like separate billing for amputation of digits and foot when performing a below the knee amputation. Edits for the current psychiatry codes are being developed.
Medically Unlikely Edits (MUE)
Codes that are unlikely to be billed together. These edits may be appealed on a case-by-case basis. For example, multiple psychotherapy sessions for the same patient on the same day. Originally, the edits were called “medically unbelievable,” but because of physician objection, the term “unlikely” was substituted for “unbelievable,” maintaining the acronym MUE. MUEs for the current psychiatry code set continue to be developed.
Consequences
- Damages up to 3 times the amount of the claim.
- Mandatory penalties of $5,000 to $10,000 per claim, regardless of the size of the claim.
- The Return-on-Investment (ROI) is about $8 for every $1 spent in the investigation. Funds are transferred to the Medicare Trust Funds ($2.5 B in FY 2012). Some of these monies are used to support the salary of the investigators.
- Whistle-blowers act in the name of the government and may seek the same damages. The Department of Justice may intercede, and the whistle-blower could still receive 15% to 25% of the claim. The whistle-blower may proceed alone and keep up to 30% of the final recovery. Such cases are also called “qui tam” cases.
As the healthcare industry moves to new care delivery and claims reimbursement standards, healthcare fraud, and abuse regulations will likely evolve as well. Providers should ensure their organizations stay up-to-date and comply with new regulations to prevent potential fraud investigations.
Another easy way to comply with all healthcare regulations is by connecting with medical billing companies. E2E Medical Billing Services is one such organization that handles end-to-end medical billing for clients. So medical service providers can focus only on patient care and they won’t have to worry about billing or coding updates or any legal compliances. To know more about medical billing and coding services, you can call us at 888-552-1290 or write to us at info@e2eMedicalBililng.com