If you are a medical professional, whether nurse, physician, technician or specialist, you may be part of a team that provides health care and compiles information about the numerous treatment details for patients on Medicare or Medicaid. However, mistakes happen. If they do, you hope that the health of the patient is not compromised, but mistakes in overprescribing, overbilling or medical coding could bring on an investigation that might affect your reputation, your career and your livelihood.
The long and winding road of information
A hospital stay is a good example of the opportunity for information errors. Treatment details are put together by many people and applied to a patient’s medical record. During pre-admission, blood tests or x-rays may be ordered, and the results must be recorded. Hospital staff will input the name, address and other contact information for the patient. Doctors and nurses will enter ongoing treatment information on a chart. Billing codes are assigned to procedures. Insurance company employees will review the types of treatment provided to decide if they are covered. When so many people touch the medical records and other documentation for one patient, errors can easily occur. Unfortunately, fraud also exists, and the perpetrator may be unknown to others on the health care team.
Unbundling and upcoding
The Federal Bureau of Investigation defines unbundling as the practice of submitting bills in “a fragmented fashion,” the purpose of which is to maximize reimbursement for services that must be billed together. For instance, if a patient is given a series of blood tests, the invoice might list several line items instead of one charge for the panel as a whole, in order to boost the cost. Upcoding is another illegal practice that refers to billing for a service at a higher level than what was provided. The bill might be for the cost of a motorized wheelchair, for example, when the patient only received a standard wheelchair.
Insufficient documentation issues
Problems can arise when a health care provider submits a document for payment that does not provide sufficient backup for the procedure code used for billing. In the case of home health services, necessary information may be missing with respect to supplies and equipment needed. The service logs might be missing, or logs might not contain the proper signatures. Even worse, there may be no indication that the services billed were actually provided.
Seeking legal help
If, as a medical professional, you are approached by a federal law enforcement officer regarding some record-keeping, coding or billing irregularity that you may or may not know anything about, stay calm and do not provide any information to the officer. Contact an experienced criminal defense attorney who will protect your rights and work diligently on your behalf.