The Nine Deadly Sins of Fraud and Abuse in a Physician Practice Print
Written by Benjamin Frosch   
Sunday, 29 August 2010 12:25

In today's health-care climate, the mere hint of impropriety can lead to investigations and/or sanctions with respect to fraud and abuse. The following are nine "sins" or traps that can put a physician smack in the middle of a government false claims allegation:

1. Continue to take your time and/or ignore billing inquiries by patients or family members.

Don't make this foolish mistake. Take every phone call and inquiry pertaining to billing from patients seriously. Remember, every Medicare beneficiary gets an Explanation of Medicare Benefits (EOMB) that includes toll-free numbers to report allegations of fraud and abuse.

2. Make a foolish decision to "complete" your medical records after you've received an audit notice from Medicare or Medicaid. 

Changing and altering medical records are both illegal and unethical unless you clearly note that the change is an addendum to the original record. Then, at a minimum, record the date you entered this change or added additional information to the medical record.  Clearly make sure that Medicare and or Medicaid is aware of your modification and when it occurred.

3. Rely on information that “Charlene" at Medicare told you.   

Now that you've verbally received billing information from "Charlene" at Medicare customer service, create a paper trail confirming the information. Document the phone call and ask Charlene where you can find the information she advised you was published, i.e., in Medicare websites, Medicare bulletins, or other literature. It's a good idea to document every call you make to Medicare. Include the issue, who you spoke to, the date and time. Do not just take her word for it. Confirm her information before billing Medicare.

4. Permit staff to re-bill all denied services for medical necessity by resubmitting a "covered" ICD-9 code without any documented clinical reason.  

This policy speaks for itself and if caught could become a nightmare. Especially when your billing staff is telling government agents it was your idea.

5. Bill for someone else's services under your provider number without full compliance of the "incident to" provision.  

With respect to physician assistants, nurse practitioners or medical assistants, there is very strict and to-the-point criteria for billing services rendered "incident to" by these individuals under your provider number. Billing hospital visits performed by your PA or ARNP under your provider number is a big no-no. The "incident to" provision was not intended for the hospital setting. If it is a true "shared visit”, the services must be medically necessary.

6. Be proud of your compliance violations. 

Brag in the doctors' lunchroom about billing all of your E&M service as level four and five visits or submitting false diagnoses to get claims paid. Some colleagues within hearing shot may get angry and advise the government of your excellent billing skills.

7. Keep purchasing diagnostic services and marking them up without letting the carrier know. 

This can cause serious problems as Medicare regulation strictly prohibits marking up purchased diagnostic services. Additionally, Medicare issued regulations and guidelines that clearly indicate how the claim is to be submitted. You must indicate on the claim what the cost of the purchased service was (to avoid a mark up), who you purchased the technical component from and meet other requirements. There are also strict rules for billing purchased interpretations. Make sure you comply with all the Medicare rules when billing globally for an interpretation you did not perform 

8. Become a  Medical Director of a  Home Health Agency, Durable Medical equipment Company, or any other Designated Healthcare Service that you refer heavily to.

Make sure you are paid exceptionally well and have no documentation demonstrating your "Medical Director" services. Most important never have seasoned healthcare lawyers review these types of Medical Director relationships or other arrangements.

9. Now that Lebron James, Dwayne Wade, and Chris Bosh are all on the Miami Heat, feel comfortable taking those great (and expensive) Miami Heat playoff tickets from healthcare providers you refer to.

After all, who would ever think that those tickets are related to your referring patients to them? You will just tell the OIG agents that you only refer patients based on "quality" and those tickets would never skew your judgment.


Benjamin Frosch is President of Frosch Medical Consultants, Inc. in Plantation, FL.


Last Updated on Saturday, 04 May 2013 15:22