One issue I see happen with medical groups or providers is when physicians or other health care providers are not properly added to the group before they provide services to patients. Often this occurs when the administrators do not ensure it is done and then when it goes to billing, the biller can't use the NPI number of the rendering provider and so they use the NPI of a different provider. This can be a false claim when done this way.
There are also complexities when a decision is made to bill the service as "incident to" a physician services but the rules here are complex and if not followed correctly that can also be viewed as a "false claim." A recent case show that this can happen at hospitals or large providers as well.
On
or about January 19, 2018, Scripps Health (Scripps), a health care system based
in San Diego, California, agreed to pay $1.5 million to resolve allegations
that it violated the False Claims Act by charging federal health care programs
for physical therapy services that were rendered by therapists who did not have
billing privileges for these programs and were not supervised by an authorized
provider. The settlement resolves allegations filed in a federal qui tam lawsuit filed by a former employee where the U.S. decided to intervene and join. The settlement is not an admission of wrongdoing.
Medicare
and TRICARE (and private insurance and Medi-Cal/Medicaid as well) limit billing privileges to enrolled providers. Services from
unenrolled providers can be billed as “incident to” the services of an enrolled
physician, but only if the physician provided direct supervision. Direct supervision is quite specific in what falls under it.
In this civil health care lawsuit dispute, the United
States alleged that Scripps billed Medicare and TRICARE for physical therapy
services provided by therapists without billing privileges and without the
appropriate supervision by a physician. The United States intervened in a whistleblower lawsuit filed by a former Scripps employee.
Suzanne Forrest, a former
Scripps employee, filed a federal lawsuit under the qui tam provisions of the False Claims Act (FCA). The FCA permits private individuals to sue for false claims on behalf of the government
and to share in any recovery. The civil lawsuit was filed in the Southern
District of California and is captioned United States ex rel. Forrest v. Scripps
Health, Case No. 16-CV-0634. As part of this settlement, Ms. Forrest will
receive $225,000.
While the claims resolved by this settlement are allegations only and there has been no determination of liability, this is an expensive lesson for the hospital. It is one that other providers can learn from. Understanding how billing "incident to" is allowed, the scope of "direct supervision," and when providers need to be added to a group or hospital will help prevent civil qui tam lawsuits, audits for overpayment and/or criminal investigations.
Posted by Tracy Green, Esq.
Green and Associates, Attorneys at Law
