Pre-payment review is also called "paper billing" and is ostensibly designed to ensure that doctors or providers submit claims within established rules and regulations, and which required them to submit documentation, including medical records, to support the services being billed to Medicare.
Under pre-payment review, claims for reimbursement that do not have the documentation necessary to support the services being billed are rejected by the Medicare contractor. When a provider is placed on pre-payment review, it is often the death knell for a health care business since collections grind to a halt and often legitimate claims are denied or rejected for arbitrary reasons. It used to be used to train providers but it is now often used as a way to shut down a provider's Medicare practice.
In this recent case, a cardiologist decided to find a way around the pre-payment review limitations which brought this civil case and a criminal case. On December 6, 2016, Vijay Patel of New Jersey, and his business Mobile Diagnostic Testing of NJ LLC were named in a civil federal qui tam lawsuit for allegedly knowingly submitting false claims to Medicare for thousands of diagnostic testing services they did not render.
The civil complaint alleges that Vijay Patel had an associate who was a cardiologist and also a Medicare provider. It is alleged that from around 2009 through 2012, the cardiologist was on “pre-payment review.” What happened is that instead of the cardiologist submitting the claims, from August 2011 through December 2012, Mr. Patel's entity and his brother's entity (Biosound Medical Services Inc. ) submitted the cardiologist's claims as if these entities had performed them instead of the cardiologist.
Once the Medicare payments for these claims were paid to the two companies for diagnostic testing services the cardiologist had performed, Mr. Patel paid a portion to the cardiologist and kept a greater portion for himself. Frankly, this is not an unusual situation where the IDTF is the Medicare provider and is paying the doctor the professional component.
Attorney Commentary: What is not clear in this case is whether the cardiologist performed the professional component while the mobile diagnostic companies performed the technical component allowing them to bill globally for the services provided. The criminal intent in this case would normally have come about IF the IDTF or diagnostic company knew that the cardiologist was on pre-payment review and that it did not add the cardiologist as a physician and/or did not use his UPIN in order to hide the cardiologist's professional interpretations.
Providers need to be very careful when hiring others to make sure they are not on any type of temporary suspension by Medi-Cal (which is not public) and are not on pre-payment review by Medicare. Medicare and Medi-Cal are becoming aggressive about this issue and have targeted providers in civil, administrative and criminal cases.
Posted by Tracy Green, Esq.
Green and Associates, Attorneys at Law
Office: 213-233-2260
Email: tgreen@greenassoc.com
