Central New York Doctor Settles Improper Billing and Controlled Substance Act Claims

Physician Admits Upcoding of Services

SYRACUSE, NEW YORK – Ahmad M. Mehdi and his medical practice, Ahmad M. Mehdi, M.D., P.C. (“Mehdi”), agreed to pay a total of $900,000 to resolve civil claims for up-coding billings for some medical services, billing for smoking cessation counseling services that were not adequately documented, and allegedly improper prescribing of opioids, announced United States Attorney Carla B. Freedman.

Mehdi operates a general medical practice with offices in Groton and Tully, New York.  According to the settlement agreement, between January 1, 2012, and September 17, 2018, Mehdi caused false claims to be submitted to federal healthcare programs by billing for some services at a higher rate of reimbursement than it would be entitled to for the service actually provided, a scheme commonly referred to as “upcoding.” Mehdi also submitted billing to federal healthcare programs for some smoking cessation counseling services that were not sufficiently documented.  This settlement also resolves claims that Mehdi violated the Controlled Substances Act between April 1, 2018, and December 31, 2020, by prescribing opioids outside the usual course of professional practice to three patients.  Mehdi has agreed to pay $331,250 to the United States to resolve all of these claims.  Mehdi will also pay $568,750 to the State of New York pursuant to the terms of a separate agreement.

“Providers who increase their own profits by over-billing for medical care increase medical costs for all of us and drain critical funds from Medicare and other government health programs,” said U.S. Attorney Freedman.  “We will continue to hold accountable medical professionals who undermine our healthcare system by over-billing for care.”

https://www.justice.gov/usao-ndny/pr/central-new-york-doctor-settles-improper-billing-and-controlled-substance-act-claims

Medicare Advantage Compliance Audit of Specific Diagnosis Codes That Highmark Senior Health Company (H3916) Submitted to CMS

What OIG allegedly found:

With respect to the six high-risk groups covered by our audit, most of the selected diagnosis codes that Highmark submitted to CMS for use in CMS’s risk adjustment program did not comply with Federal requirements. For 66 of the 226 sampled enrollee-years, either the medical records validated the reviewed HCCs, or we identified another diagnosis code (on CMS’s systems) that mapped to the HCC under review. However, for the remaining 160 enrollee-years, the diagnosis codes were not supported in the medical records. These errors occurred because the policies and procedures that Highmark had to prevent, detect, and correct noncompliance with CMS’s program requirements, as mandated by Federal regulations, could be improved. As a result, the HCCs for these high-risk diagnosis codes were not validated. On the basis of our sample results, we estimated that Highmark received at least $6.2 million of net overpayments for 2015 and 2016.1

https://oig.hhs.gov/oas/reports/region3/31900001.pdf

Watertown Medical Practice to Pay $850,000 to Resolve False Claims Act Allegations

ALBANY, NEW YORK – North Country Neurology, P.C., a physician-owned medical practice located in Watertown, New York, has agreed to pay $850,000 for what it admitted was “improper” and “reckless” billing to the federal government for medical services, announced United States Attorney Carla B. Freedman.

“The integrity of our federal health care system depends on accurate and honest billing by medical providers,” said United States Attorney Freedman.  “While North Country Neurology will pay a steep price for submitting false claims for payment to Medicare, I commend the practice and its management for accepting responsibility for its past actions and for implementing forward-looking compliance measures in response to our investigation to assure systems are in place to facilitate and promote ethical and legal conduct in the future.”

North Country Neurology employed physicians and a physician assistant who rendered care to Medicare beneficiaries.  In certain circumstances, Medicare allows practices to bill for services rendered by a non-physician practitioner (NPP), including a physician assistant, “incident to” the services that are personally rendered by a physician.  These services, even though not personally rendered by a physician, may be billed in a physician’s name if several requirements are met.  One such requirement is that a physician directly supervise the NPP rendering the services, meaning that a physician is present in the office suite and immediately available to furnish assistance and direction throughout the procedure.  Although Medicare will reimburse practices for certain procedures rendered by NPPs without a physician’s direct supervision, such services are reimbursed at a lesser rate than service rendered or directly supervised by a physician.

North Country Neurology admitted that, on 120 occasions from September 2015 through June 2019, it “submitted or caused to be submitted claims for payment to Medicare that improperly listed a physician as the rendering provider for services rendered by a physician assistant when no physician was physically present in the office and immediately available to furnish assistance and direction throughout the performance of the procedure.”  The practice further admitted that it “knew or should have known the requirements of incident-to billing and that it was improper to submit claims to Medicare in a physician’s name for services rendered by an NPP when no physician was in the office” because, among other reasons, its billing company had informed the practice’s owner of separate incident-to billing violations several years earlier.

https://www.justice.gov/usao-ndny/pr/watertown-medical-practice-pay-850000-resolve-false-claims-act-allegations

Metroplex Pain Consultants and Dr. Steven Casey Agreed to Pay $110,000 for Allegedly Violating the Civil Monetary Penalties Law by Submitting Claims Dr. Casey Did Not Perform or Directly Supervise and Claims for Excessive Services

On March 2, 2022, Metroplex Pain Consultants, LLC (Metroplex) and Dr. Steven Casey (Dr. Casey), Dallas, Texas, entered into a $110,748.12 settlement agreement with OIG. The settlement agreement resolves allegations that Metroplex submitted claims for services purportedly rendered by Dr. Casey during a time period when Dr. Casey was not at his office. Additionally, OIG alleged that Metroplex and Dr. Casey submitted claims to Medicare for spinal facet joint injections, which amounts exceeded five in a rolling 12-month period. OIG’s Office of Audit Services and Office of Counsel to the Inspector General, represented by Gregory Becker, collaborated to achieve this resolution.

https://oig.hhs.gov/fraud/enforcement/metroplex-pain-consultants-and-dr-steven-casey-agreed-to-pay-110000-for-allegedly-violating-the-civil-monetary-penalties-law-by-submitting-claims-dr-casey-did-not-perform-or-directly-supervise-and-claims-for-excessive-services/

Dr. Meir Daller Agreed to Pay $455,000 and Be Excluded for 3 Years for Allegedly Violating the Civil Monetary Penalties Law by Submitting False and Medically Unnecessary Claims Associated with rology Services

On November 30, 2021, Meir Daller, MD (Dr. Daller), Fort Myers, Florida, entered into a settlement agreement with OIG in which he agreed to pay $455,400 and be excluded from participation in all Federal health care programs for three years under 42 U.S.C. 1320a-7a and 42 U.S.C. 1320a-7(b)(7). The settlement agreement resolves allegations that Dr. Daller submitted or caused to be submitted the following: (1) claims for cystourethroscopy with dilation of urethral stricture where no stricture was present that necessitated urethral dilation; (2) claims for urodynamics testing that was ordered on a routine periodic basis, not out of medical necessity; and (3) claims for evaluation and management (E&M) services related to in-office testosterone injections that were: (i) submitted in conjunction with claims for the testosterone injections, using modifier 25, where no significant and separately identifiable service other than the testosterone injection took place; and (ii) submitted alone where the patient received an in-office testosterone injection but no evaluation or management of the patient took place that justified the billing of an E&M code. OIG’s Division of Data Analytics and Office of Counsel to the Inspector General, represented by Senior Counsels Michael Torrisi and Srishti Sheffner with the assistance of Chief Investigator Amber Mahmood and Program Analyst Mariel Filtz, collaborated to achieve this resolution.

https://oig.hhs.gov/fraud/enforcement/dr-meir-daller-agreed-to-pay-455000-and-be-excluded-for-3-years-for-allegedly-violating-the-civil-monetary-penalties-law-by-submitting-false-and-medically-unnecessary-claims-associated-with-urology-services/

Medicare Advantage Compliance Audit of Diagnosis Codes That Humana, Inc., (Contract H1036) Submitted to CMS

What OIG allegedly found:

Humana did not submit some diagnosis codes to CMS for use in the risk adjustment program in accordance with Federal requirements. First, although most of the diagnosis codes that Humana submitted were supported in the medical records and therefore validated 1,322 of the 1,525 sampled enrollees’ HCCs, the remaining 203 HCCs were not validated and resulted in overpayments. These 203 unvalidated HCCs included 20 HCCs for which we identified 22 other, replacement HCCs for more and less severe manifestations of the diseases. Second, there were an additional 15 HCCs for which the medical records supported diagnosis codes that Humana should have submitted to CMS but did not. Thus, the risk scores for the 200 sampled enrollees should not have been based on the 1,525 HCCs. Rather, the risk scores should have been based on 1,359 HCCs (1,322 validated HCCs + 22 other HCCs + 15 additional HCCs). As a result, we estimated that Humana received at least $197.7 million in net overpayments for 2015. These errors occurred because Humana’s policies and procedures to prevent, detect, and correct noncompliance with CMS’s program requirements, as mandated by Federal regulations, were not always effective.

https://oig.hhs.gov/oas/reports/region7/71601165.pdf

Medical Coding & Billing Due Diligence Before Medical Practice Merger or Acquisition

Why Are Medical Coding & Billing Due Diligence Important?

There are numerous reasons why you would want to engage in thorough medical coding and billing due diligence before a practice merger or acquisition. However, the most important is to ensure compliant and accurate documentation, as well as timely and accurate coding and billing.

By checking into this history, you can determine a lot about the financial well-being of a practice, including how it affects the overall value. Additionally, non-compliant billing and coding can increase the liability risk for a medical practice. If you are taking control of that practice, that liability carried onto you. Thus, it is important to know what you are dealing with from the very beginning by doing a thorough job of due diligence.

Coding Due Diligence Benefits

It’s important to realize that the benefits of coding due diligence go far beyond just checking for liability issues. For example, you can enjoy greater visibility in coding patterns and have a more complete basis for your purchasing decision.

Working with Symbion Coding Inc to obtain this type of report also ensures diagnoses and procedures described in the patient’s health records are appropriately coded. In turn, this allows you to identify whether the risk lies with the physician, coders, or some combination thereof.

Working with Symbion for Coding Due Diligence

At Symbion, we are here to make the due diligence portion of your acquisition or merger easy. Our experts can help detect a variety of elements including:

  • Whether E/M documentation meets all appropriate guidelines or not
  • Any possible missed opportunities for HCC codes for Medicare Risk Adjustment
  • Determining if diagnosis and procedure coding guidelines are followed
  • If file documentation routinely supports medical necessity
  • Whether medical records are being copied and/or pasted versus individually prepared for each unique patient

And that is just the start of what we’re usually able to uncover. By having these details, you can make a better determination and wiser decisions during your business transaction.

adobestock 220427469

Receive a Complete and Detailed Report from Symbion

So, what does Symbion provide with our medical coding and billing due diligence service? First, we offer a quick turnaround time to help you get the information you need when it is most important. Second, the report we offer is fully confidential and we also routinely work with attorneys to ensure attorney-client privilege. In the end, you will receive a report that not only shows errors, but also identifies possible root causes, opportunities for documentation improvement, analysis of results with potential impact, and recommendations to address the identified issues.

Why Your Medical Practice Needs a Clinical Documentation Improvement (CDI) Program

As most practitioners and nurses would agree, health records are the most critical document used within the medical care setting. After all, they are the primary vehicle for recording and communicating health information and ensuring continuity of care.

There are numerous pieces of information within a health record that are used for various purposes. For example, notes and information within these documents are used to evaluate adequacy and appropriateness of care. They also provide clinical data for research and show quality of care. On the financial side, these records can support reimbursement from insurance providers and make keeping the healthcare center profitable a reality.

In short, documenting the patient’s condition completely and accurately is a paramount part of the healthcare process. That is why it is so important to review your document program and have a plan for making needed changes for better accuracy.

What is a Clinical Documentation Improvement (CDI) Program?

So, what exactly is a clinical documentation improvement (CDI) program? Essentially, it is the process of improving healthcare records to ensure improved patient outcomes, data quality, and accurate reimbursement. The overall goal is to ensure the patient’s true severity of illness is documented and reported appropriately.

While that might all sound like a mouthful, what it all comes down to is having a process of reviewing your documentation to make sure your entire medical team is reporting healthcare data accurately and completely at all times. This is something that needs to be done often to ensure all protocols are followed and that your patients are getting the best care possible. It is also something that should be checked to discover any bad habits or problems that arise with specific staff member reporting.

Reasons for Clinics to Implement a CDI Program

Hospitals have been doing inpatient CDI programs for years and regularly make changes to their documentation protocols. The unfortunate part is that most individual clinics and doctor’s offices don’t have the same level of funding to be able to do this on a regular basis, nor does the staff usually have time in the day due to other responsibilities.

Think about this for a moment. What time during the day does an office manager or receptionist have to go through existing medical records and review them for complete and total accuracy? What about a medical biller or coder? Generally, their day is busy with just trying to keep up with the normal duties of their position. Thus, it can be a good idea to work with a third-party to implement a thorough CDI program.

Clinical Documentation and the Changing Healthcare Environment

The healthcare environment is rapidly changing, and it can be more critical than ever to ensure all patient health records are accurate and complete. In order to receive payment for health services rendered, the quality of records submitted can make a big difference in amount and speed of pay.

Payment systems utilizing ACOs and bundled payments incentivize efficient care, but also require physicians to document specifically, clearly, and accurately. In addition, the Physician Quality Reporting System (PQRS) also offers better benefits for having better health record documentation.

Plus, many health payers now use some version of value-based reimbursement that links financial reimbursement to patient severity of illness. This means that it is more vital than ever to capture and record accurate diagnoses.

What Can Individual Medical Practices Do?

When it comes to ensuring your individual medical practice has the most accurate health records possible, one option to consider is to hire a third-party to implement a CDI program. On a small scale, your organization can hire a medical coder with specific CDI experience to help review existing records and implement better protocols for new records.

Likewise, you can also opt to work with a third-party coding and billing partner, such as Symbion Coding (www.symbioncoding.com). We offer clinical documentation improvement advice and review within the services that we already offer, which can give your practices a two-fold approach to improved reimbursement and accuracy.

Both are excellent options that lead to one final and successful result: a better healthcare records system that ensures your patients are getting the best care possible and that your practice is receiving the appropriate reimbursement for the treatment provided.

Conclusion: Benefits of Having a CDI Program

What this all comes down to is that every medical practice should have a CDI program in some form. Whether this is an individual party who is trained to handle chart review tasks or a third-party organization with a wealth of experience analyzing records in bulk really comes down to your individual clinic needs.

However, the end result is still the same of better-quality documentation within the medical record. Better data and accurate reimbursement for the practice. And an overall reduced compliance risk associated with improper billing. For most practices, these benefits alone far outweigh the cost of hiring third-party help and make the CDI process incredibly worthwhile.

jeans photo
Jean Delva
Founder & CEO of Symbion Coding, Inc.

How to Document Telephone Encounters?

There is no doubt that the COVID-19 pandemic has changed the medical community as a whole. Where most people used to just make an appointment and show up at the office, many are now opting for telephone encounters to help prevent virus spread.

For practitioners, this is a much more convenient way to offer patient centered care. Instead of trying to see a set number of people within the walls of the office each day, doctors can now treat more patients in a much more convenient format.

Here is what you need to know about telephone encounters including what they are and why they need to be documented correctly.

What Are Telephone Encounters?

page 2 image 2

Simply put, telephone encounters are clinical exchanges that occur via telephone between providers, nurses, and patients. Telephone encounters can be very useful for numerous reasons, including:

  • Increased Clinic Access: Patients who might not otherwise be able to make it into the clinic physically now have access to care.
  • Reduced Unnecessary Burden on Patients: Travel time and other obstacles are now reduced or completely eliminated.
  • Reduced Unnecessary Hospital Visits and/or Readmission: By having easier access to primary care physicians, less patients are physically visiting emergency medical centers.
  • Improved Continuity of Care: Subsequent visits to follow up for specific conditions is much easier.
  • Maximize Physician and Nurse Time: Calls usually only last a few minutes, which allows for treatment or more patients within a day.

In short, there are many reasons why a practitioner would consider adding telephone encounters to their schedule that are beneficial to the overall clinic (This article does not examine the amount pay by health plans to medical practices).

Not All Phone Calls Are Telephone Encounters

However, it is important to realize that not all phone calls are telephone encounters. Knowing the difference is important, as it can mean the difference between having bills approved by insurance companies or outright denials.
The real benchmark is whether or not the call includes information that can be communicated by non-licensed staff. This includes communication of normal results, billing inquiries, or other generic phone calls. Additionally phone consults that result in an in-person appointment less than twenty-four hours later would not be considered a telemedicine visit.

Criteria for Telephone Encounters

To ensure practitioners are using the telemedicine system appropriately, there are a few guidelines that determine whether an event is truly a telephone encounter. At least one piece of criteria must be met to be considered an eligible telephone encounter:

  • Medical Decision Making: The call includes medical decision making and/or care coordination that results in the involvement of a physician, nurse, or pharmacist, such as treatment plans or changes in prescription medication.
  • Substitute for In-Person Clinic Visits: To be a telephone encounter, the call must be deemed an alternative for a physical visit to the clinic.
  • Refills of Medications: The call includes refills of medications that would have otherwise required an in-person clinic or emergency room visit.
  • Follow-Up Visit: The conversation serves as a follow-up to a previous in-person visit.
  • Educational Visit: The call or involves a form of patient education such as counseling, informed consent, or motivational interviewing.

Furthermore, it is important to note that only established patients are eligible for legitimate telephone encounters.

Documentation of Telephone Encounters

When it comes to medical billing and coding, there is a specific amount of documentation that needs to be done correctly. All telephone encounters should be documented to the medical record in the same manner as an in-person clinic visit. A few of the most common documentation requirements include:

  • Notation of Initiation: It should be well documented that the patient, parent, or guardian initiates the phone call.
  • Notation of Consent: Documentation that the patient consents to the telephone call.
  • Notation of Reason: Include notes on the reason or chief complaint requiring the telephone call.
  • Medical History: Document relevant medical history, background, and/or results for the patient.
  • Assessment: The practitioner’s assessment of the patient with full and detailed notes.
  • Treatment Plan: The provider’s plan for treatment of the patient, including all relevant medications or other instructions.

It is also important to include detailed information to show the medical necessity on the total time spent with the patient. While it might be tempting for some patients to discuss their grandchildren’s soccer game or some other personal topic, this filler conversation should not be included in the documentation.

Wrap Up: Protecting Your Practice During Telephone Encounters

It continues to look like telephone encounters are going to stay popular long after the COVID-19 pandemic fades. That is why it is so important to learn these guidelines now and apply them within your practice. Failure to do so can lead to denials and delay of payment, which nobody wants to deal with. Instead, train your team now to help make the billing and coding process easier in the future.