Protecting against unethical and fraudulent medical billing

SAN FRANCISCO — Physician assistants and nurse practitioners should be vigilant for unethical billing procedures that could unknowingly put them at legal risk, according to a speaker here.

“You have a professional obligation to report unethical or potentially harmful medical practices and suspected over billing or fraudulent billing,” Jeffrey G. Nicholson, PhD, PA-C, MPA-S, DFAAPA, said at the American Academy of Physician Assistants 2015 meeting. “PAs will be liable if billing fraud is committed with their national provider identifier (NPI).”

Nicholson, the founder of PA Experts Network, a medicolegal consulting business, has more than 23 years of clinical practice as a clinic owner and medico-legal consult. He offered the following tips for spotting these types of behaviors and suggested ways for clinicians to protect themselves. 

Get to know your coding and billing staff. “Go over some patient records from your own patient encounters with them and get some tips to understand what meets a level 3 for a new patient, what meets a level 4 for an established patient, and learn how to put in your record what would be the appropriate coding level. This is not a topic that is well taught in our PA programs. Most PAs don't get involved in this detail of coding, but I encourage them to learn it anyway, because it's critically important to what they do.”

Check your supervising physician's credentials. “There are some who are not exactly honest when it comes to coding and billing, especially with government payers such as Medicare and Medicaid. You need to know if they've ever been disciplined by their state's Medical Examining Board. Look at the National Practitioner Databank to see if any disciplinary actions were sanctioned against them.”

Make sure your work is billed under your NPI. “There are certain instances where you can get more money from Medicare for billing under the physician provider number, but you have to meet certain criteria to do that. There are a lot of clinics out there that are inappropriately billing as if the physician saw the patient rather than the PA, and that can get you in big trouble. If you are billing under the physician's NPI number, make sure the encounter meets 'incident to' criteria.”

Observe clinic staff and physicians attitudes about the current health care payment system. “You'll know very quickly, within a month of working for a particular employer's office what kind of an attitude is prevalent. If they have an axe to grind, that's a red flag that there might be a tendency to do some cheating when it comes to billing.” 

Understand what drives the health care payment system. “This will help you understand why there possibly is a tendency to commit fraud on either end of the spectrum.The primary care clinicians are getting paid the least are going to feel unjustly paid and may tend to feel cheated and see patients more often or over code or over bill,” Nicholson said. “On the other hand certain specialists have what I call 'cash-cow procedures' and may skew their practice to perform as many of these procedures as they can, even if not indicated, so they see patients in which they can perform the most highly billable procedures.”

Physician assistants should play an active role in health care policy debates, Nicholson encouraged. “The problem is not what can we do about the skyrocketing costs of healthcare, but what can we do about the skyrocketing costs of health care profits and profiteering.” 

Editor's Note: Look for further articles and discussions with Jeff Nicholson on this topic in future articles on The Clinical Advisor.

References

  1. Nicholson JC et al. "Medical Practice Ethics for PAs.” Presented at: AAPA 2015. May 23-27, 2015. San Francisco, California. 
Loading links....
You must be a registered member of Clinical Advisor to post a comment.
close

Next Article in AAPA 2015 Annual Meeting