Category: Legal Department

Metzinger Associates, a billing consulting company, allegedly devised and implemented a scheme for maximizing reimbursement. The Metzinger group used improper coding methods, which included up-coding, unbundling and rebundling, to obtain a higher amount of reimbursement, and provided these services to their clients.

In order to avoid criminal liability, the owners of Metzinger agreed to cooperate with the government in the civil and criminal prosecution of their clients. In addition to providing the government with a list of their clients, they also provided 250 consulting hours to the government and provided the government with documents, records, computer runs, and other information with regard to other consultants, doctors, coding and billing techniques.

Billing companies can be very useful in running an efficient practice; but, if your billing and coding company is providing you with methods of billing and coding that sound too good to be true, watch out!

When negotiating with a billing company, ask what they do to stay in compliance. Find out if they use a Compliance Manual.  Billing companies that provide coding services should have extensive policies in place to ensure proper coding.

Ask how they pay their employees. Make sure that there are no financial incentives to employees to up-code or un-bundle claims.

If you have any questions with regard to the above  or with respect to any other legal heath care issues, feel free to FAX your questions to Deborah A. Green, Esq., at 954-971-3787 or call 954-971-7778 or email [email protected].  She will answer those questions which are of interest to the broadest audience, in future columns.

Ms. Green has been a practicing attorney since 1977. She is admitted to the practice of law in the State of New York and Florida and is a member of the American Health Lawyers Association, the New York State Bar Association Health Care System Design Committee, the New York State Bar Association Health Care Providers Committee, the American Bar Association Health Law Section and the Florida Bar Health Law Section. She has formed numerous multi-discipline practices throughout the country.

DISCLAIMER

Because this column is being presented to you by an attorney, it would not be complete without a disclaimer. This column is provided subject to and governed expressly by the terms of this disclaimer. This column is provided for educational purposes only. The accuracy or timeliness of the information presented herein is not warranted. The information presented herein is not intended to be advice as to a specific fact pattern with which you may be presented.  Accordingly, please note that the information contained herein is not being presented as legal advice with respect to any matter and that no attorney-client relationship is hereby established.

Are health care fraud investigations and criminal indictments brought only against the guilty?

The short answer is no.  Given the right circumstances, the likelihood of finding oneself fighting against a criminal indictment based on billing mistakes is high.

The writings of Franz Kafka involve situations of surreal distortion accompanied by a sense of impending danger. A story along those lines well illustrates the problem.

Meet David. Despite a touch of Attention Deficit Disorder, he’s had a successful chiropractic practice for over thirty years.  He’s refused to allow modern advancements to pass him by, so he’s tried to remain on the cutting edge of chiropractic care, getting advanced training in EMG application and ultrasound techniques.  He purchased a hydro bed and, following the suggestion of the manufacturer, coded its use as whirlpool therapy for some time.  He’s worked with a neurologist and, like some others at the hospital, coded some incidental billing under the doctor’s provider number.  His practice is doing well.

Yet suddenly he has a problem.  Bill, a former office manager and business associate, is disgruntled.  A venture went south.  David is blamed.  Recrimination follows. Bill wants money.  David refuses. Bill mails a letter to the FBI, accusing David of wrongdoing for performing pelvic ultrasounds and nerve conduction tests without formal certification, up-coding hydro bed therapy as whirlpool, and billing services using a medical doctor’s provider number. David reviews his EOB forms and mails back some money to cover the cost of many of these billings.  If these were errors, others have made similar mistakes.  Who would believe Bill?  The state board doesn’t offer clear guidelines and he’s provided ten times as many free services as these questioned claims.

David is indicted for 552 criminal counts, ranging from mail fraud to money laundering.  Seizure warrants are issued against his investments. Many of his patients disappear.  Insurance companies refuse to pay his claims. The United States Attorney, influenced by investigators who know little about health care billing practices, assumes his guilt. After consultation with health care billing experts and analysis of eight thousand pages of documents, David’s 552 count indictment shrinks to 3 counts, offered to the government like poker chips slid across a table.  After making a payment of $50,000 to free his investments, he wonders whether Franz Kafka was ever a gambler.

Larry Economos, a civil and criminal defense attorney whose practice focuses on federal health care fraud defense, is a managing partner with Mills & Economos, LLP. Mr. Economos can be contacted via his website address, www.leconomoslaw.com, or by telephone at 800-456-0460, 704-375-9913, or 252-752-6161.