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21 posts from May 2009

May 29, 2009

Podiatrist Gets Sentenced in Medicare Fraud Case

Major Medicare fraud and false claims settlements against large providers and pharmaceutical and device companies are reported in the news on a regular basis these days.  Unfortunately this trend may lead many physicians to believe that their billing and collection activities are under the radar of federal and state enforcement authorities.  According to an article in the Scranton Times-Tribune, when it comes to Medicare fraud, size doesn't matter. 

According to the article, a Scranton podiatrist was sentenced this week to two years of probation and ordered to pay $23,266 in restitution for submitting false claims to Medicare.  What is significant about this case is that the podiatrist reportedly only received between $10,000 and $30,000 in improper payments from the Medicare program.  So, if you still think your practice is too small to get noticed, think again. 

The prospect of developing a full-blown fraud and abuse compliance plan may seem overwhelming for many physicians but a compliance plan is really the only "insurance" you can put in place to help minimize legal exposure from improper billing.  Consider starting small.  An annual coding and documentation audit with the help of a health care attorney and billing consultant is hands-down one of the best things you can do from a compliance standpoint and it need not be expensive.  Most importantly, however, when if comes to compliance, doing something is far better than doing nothing.  For more information on developing a cost effective compliance plan, see the article "Compliance Planning on a Shoestring Budget"www.physiciansnews.com/law/1107rodriguez.html.

May 28, 2009

Dealing with Insurance Reps

A recently posed question by a client:

In my medical office, I am sometimes asked to call insurance company representatives to inquire about payments or for updates to patient info. Most reps are polite and helpful when I call, but I am having problems with reps at one particular insurance company. No matter whom I speak to, they always seem to be pushy, cold and short with me. I don’t like it, but I don’t want to hurt our office’s relationship with the carrier. What I can do about it?

If your job requires you to talk to insurance company representatives, you may run into an unpleasant rep from time to time. When this happens, keep your cool - you will stand a better chance of getting what you want if you mind your manners. Yelling and a bad attitude will do little to help your case when dealing with insurance companies.

Make every attempt to resolve all issues in a friendly yet professional manner. Unfair as it may seem, insurance reps are likely to disregard your call and your requests if you are nasty and negative on the phone. Payers have been known to drag their feet in response to a feisty payee. And this only makes your job harder both now and in the future, not to mention slowing payments. So, next time you feel like screaming, think long-term, then grit your teeth and be pleasant. Get your point across - just do it tactfully.

May 27, 2009

Call Back Success Tactics

One of the most common reasons I see patients get upset with medical offices is that they don’t get a call back when promised (this is especially true when I’m the patient and don’t get my call back!). So here are a few practical tips you should consider:

Confirm: Always read back the information the patient gives you. This will make sure everything is correct. Also, it shows the person you’re really paying attention and taking her message seriously.

Multiple Phone Numbers: Obtain multiple phone numbers for the doctor or nurse to call the person back. This is important because the patient may want to give you his work number when he calls to speak to the provider who will actually be calling him back at home later that evening.

Follow Up: Be sure to get back to the patient if your physician isn’t able to call back at the agreed-upon time. For example, you might call the patient and say, “All of your test results aren’t going to be in today, so we need to reschedule your chat with the doctor”.

May 26, 2009

Restrictive covenants protect against competitive practice

A restrictive covenant on your existing partners is important to governing the practice for its own success. For starters, if you don't impose such restrictions on yourselves, you will find it difficult to justify them to young doctors you bring into membership.

Many groups flounder because they accommodate their partners' varied priorities rather than their best organizational goals. The solution: Make all partners subject to restrictive covenants. In addition, having the restriction apply to all says that the group is more important than any partner.

Yet, even if logical and correct, this advice may not convince a partner to surrender present freedom to stay or leave at will. But if you recognize that your long-term security depends on group success, you may have to accept restrictions.

May 22, 2009

10 steps to safeguard your data

Every practice needs to develop safeguards to prevent the unauthorized disclosure of information from a physician practice by a health plan or other source. In an age of data transparency, however, no strategy is bulletproof. Moreover, if it is found that disclosure is in the public interest, it may not be possible to block it completely. So consider the following 10 steps:

  1. Identify the source that is disclosing information about your practice and verify that the information was intended to be kept confidential.
  2. If a payer is making the disclosure, consider whether circumstances might now warrant the disclosure.
  3. If the disclosure is coming from a payer, and you decide to protest, look in your contract for exactly what is specified about the type of disclosure.
  4. If the contract is silent and you decide to object, consider sending a letter that places the payer on notice that you consider the information confidential and not subject to disclosure. Cite your reasons and note that the agreement does not expressly authorize the disclosure.
  5. Ask for advance notice of the publication of any information about your practice and the opportunity to review the information for accuracy.
  6. Contractually agree to the publication of data that are compiled only by trusted sources, and require review and approval of any homegrown content.
  7. Ask for the ability to review and comment on the explanation accompanying the information.
  8. Offer objective information about your practice that provides value to patients, including estimates of the cost of services for a particular service or procedure. Make note of any individualized financial counseling that you offer to patients.
  9. Consider developing your own Web page to provide specific information about the cost and quality of your services.
  10. Ask the payer to link your explanation about cost and quality information to its comparative data.

May 21, 2009

Government can and will place a levy on your Medicare pay if you owe taxes

If you owe back taxes, expect the IRS to come calling in non-traditional ways -- in fact, they might just garnish some of your Medicare reimbursement until you’ve paid back what you owe. According to CMS Transmittal 368 businesses that owe tax money to the IRS may face levies.

CMS may reduce federal payments subject to the levy by 15 percent, or the exact amount of the tax owed if it is less than 15 percent of the payment,” the transmittal indicates. The levy is continuous until the overdue taxes are paid in full, or other arrangements are made to satisfy the debt. So if you owe back taxes, the IRS will arrange to take 15 percent of your Medicare reimbursements until your levy has been satisfied.

If the government has garnished part of your Medicare reimbursement, you’ll see the code “WU” in the PLB03-1 data field, along with Medicare’s phone number in case you have questions about the adjustment.

To read the complete CMS transmittal, visit the CMS Web site online at


To review the related MLN Matters article, visit the CMS Web site at


May 20, 2009

Is There a Fraudster in Your Organization? 16 Things to Watch For

An embezzler or other workplace fraud perpetrator will often display certain telltale red flags. One of the many charts included in the "2008 Report to the Nation on Occupational Fraud & Abuse," published by the Association of Certified Fraud Examiners, includes the following listing of these behavioral indicators:

  1. Living beyond means (370 cases; 38.6% of 959 total cases in the study)
  2. Financial difficulties (327; 34.1%)
  3. Wheeler-dealer attitude (195; 20.3%)
  4. Control issues, unwillingness to share duties (179; 18.7%)
  5. Divorce/family problems (164; 17.1%)
  6. Unusually close association with vendor/customer (146; 15.2%)
  7. Irritability, suspiciousness, or defensiveness (130; 13.6%)
  8. Addiction problems (128; 13.3%)
  9. Past legal problems (83 cases; 8.7%)
  10. Past employment-related problems (76; 7.9%)
  11. Complaining about inadequate pay (70; 7.3%)
  12. Refusal to take vacations (65; 6.8%)
  13. Excessive pressure from within the organization (62; 6.5%)
  14. Instability in life circumstances (47; 4.9%)
  15. Excessive family/peer pressure for success (40; 4.2%)
  16. Complaining about lack of authority (35; 3.6%)

Download the complete 2008 Report to the Nation on Occupational Fraud & Abuse

May 19, 2009

Lessons in professionalism from a former medical administrator

In the recent issue of MGMA e-source, there was a reprint of an article by Mark G. Sanders, CPA, a former MGMA member and now owner of MGS Consulting, Louisville, Ky.

Almost four years after the physicians in the practice he ran took the advice of a consultant, he was fired along with other senior staff and the consultant was appointed the new CEO of the group. Now, three doctors have escorted him from the building. They had had enough. But to Mark’s credit he wrote, “It’s no time to gloat or say, I told you so. It's time to grieve for a practice that lost a great deal in a short time.”

The consultant had proceed to damage, dissolve or disrupt physician-to-physician, physician-to-hospital and physician-to-teaching-institute relationships that had been in place for decades. So how could the physicians allow this to happen to their organization? Here are six take-aways Mark got from it and they are dead on:

  • Be prepared – all practices change
  • Many people – physicians included – avoid conflict and frequently acquiesce to whoever makes the most noise
  • Establish an employment agreement that stipulates, among other things, what "the end" looks like
  • By the time you believe an employment agreement is a good idea, it's probably too late to get one approved
  • Physicians need to understand that the grass is not always greener for them somewhere else
  • There will always be someone who says he/she can do your job better than you can

This is good advice for all medical practice administrators and something all should think about it. Practices are “changing” all over the place right now, so be prepared. Physicians, you should think about this too.

May 18, 2009

Design a fair retirement exit

Physicians generally enjoy more flexibility regarding retirement than do members of many other professions. But sometimes a declining doctor refuses to acknowledge his or her diminished capacity, causing a confrontation that's often embarrassing.

You can reduce your chances of facing such a showdown with a sensible mandatory retirement age that includes extension options. First, provide that a doctor must retire at a stated age, often 65 or 70. But allow him or her to apply in advance each year for an extension.

Require the senior to apply at least six months before the mandatory retirement date, after which the group must vote yea or nay within two months. A competent doctor can thus continue past mandatory retirement age if it really suits the member and the group.

p.s. Don’t forget to follow me on twitter: www.twitter.com/rtacpa

May 16, 2009

Does Overhead paging = HIPAA violation?

Reproduced from [name of publication] © 2008 HCPro, Inc., 200 Hoods Lane, Marblehead, MA 01945. 781/639-1872. www.hcpro.com. Used with permission.

So is overhead paging a patient by name back to a clinic or hospital area a HIPAA violation?  Well it depends on whether the name of the clinic or area would reveal anything about the patient’s condition. Paging, “John Jones to report to the HIV Clinic,” would obviously violate his privacy. Paging him to the Medicine Clinic would reveal much less information. A better approach, though, would be to ask the patient to dial a specific extension for more information (e.g., “John Jones, please call extension 2500”) if possible.

All healthcare organizations should attempt to significantly limit the amount of overhead paging that staff members do, to both protect patient privacy and minimize disruptions to others. Some organizations actually give patients flashing pagers, similar to those used to in restaurants, to notify them when to return to treatment areas.