Author Bio:
Sharon Hollander is an author, entrepreneur, and a healthcare
consultant in the area of practice management
for over 30 years. She is a leading expert in the area of physician billing and reimbursement. Currently the President of STAT Medical Consulting, a comprehensive medical billing service in Encino, California providing billing services to physicians and surgeons in solo practice or small group practices.
for over 30 years. She is a leading expert in the area of physician billing and reimbursement. Currently the President of STAT Medical Consulting, a comprehensive medical billing service in Encino, California providing billing services to physicians and surgeons in solo practice or small group practices.
Author Links -
facebook: authorsharonhollander
Twitter: @hollandersharon
Linkedin Sharonhollander
Goodreads: Sharon Hollander Medical
Billing Horror Stories
Amazon: Sharon Hollander
Blog: Sharonhollander.com/blog
Book Genre: Non Fiction
Publisher: Abbott Press
Release Date: July 2013
Book Description:
Anecdotes and real case studies ripped from the headlines about what
doctors did which got them into trouble either with Medicare, HIPPA,
The Office of Inspector General or worse the FBI.
The case studies presented within these pages are true stories of
medical professionals: Some are about providers just like you. Many
doctors are just trying to navigate the maze of the medical billing
process.
Many providers thought that if they only bill just 99213’s, they
could stay under the radar. What they didn’t expect is that by
doing this and not varying their coding appropriately, they were
raising red flags about their billing practices which led to them
being audited by Medicare.
With the changing rules and regulations and challenges facing
healthcare, you cannot afford to miss this information.
If you submit even one claim for reimbursement this is a
must read!
Excerpt:
One
winter morning a doctor, called Dr. Winters received a phone call
from one of his patients.
“Dr.
Winter, I am really upset.”
“And
why is that Mr. Jones?” the doctor asked innocently.
“I
recently got hired by a new company, and well they are requesting a
pre-employment physical.”
“Well
I have seen you recently, has anything changed for you? You were in
good health when I saw you last.”
“Well,
here is the thing, doc, I am feeling fine, actually better than
ever,” said Mr. Jones
‘Okay
so what’s the problem?”
“They
denied my employment, and told me to contact my doctor.”
‘That’s
unusual. Did they tell you why?”
“No,
just that I better call you as soon as possible.”
“Okay
why don’t you schedule an appointment with my office, and we can
run some tests to see what if anything is going on.”
‘Okay
thank you doctor.”
The
patient had a battery of tests and a complete physical and all were
normal. Dr. Winters released Mr. Jones back into the world, and told
him if he develops any kind of symptoms to contact him. As one would
expect three months went by and Dr. Winters never gave Mr. Jones and
the mystery of why Mr. Jones was denied employment another thought.
About
three months later, Dr. Winters received a note from Medicare
requesting about twenty of his charts for a post-payment review, sort
of a mini audit. He was upset. A doctor hears audit, and well it
would be the same as if the IRS came a knocking. His staff pulled
the twenty patient files and Dr. Winters reviewed the patient’s
clinical notes he had well documented in the medical records.
The
first patient had been congestive heart failure, and the patient was
anxious about whether to undergo a CBBGE bypass surgery. The next
patient had a rotator cuff injury and was also worried about his
ability to play pro-baseball if he had his surgery. The third was a
patient that had experienced symptoms of a heart attack, but it was
deemed to be just anxiety.
After
careful review, he copied the records and sent them off to Medicare.
Another three months passed, and then he got a notice from Medicare
to refund two thousand dollars, based on their audit findings.
Needless
to say, Dr. Winters was pissed. Of course, Medicare requested this
information on the day before he was to leave on a much deserved
vacation. Well, he cut the check and sent the funds to Medicare.
Most physicians may have left it at that, but Dr. Winters was peeved
at Medicare, and personally resolved to get to the bottom of this
outrage.
He
had his staff call Medicare, but they were not able to determine the
cause of the problem. Finally after his own frustration escalated he
resolved to solve the case of the audit himself. Two hours and
countless phone transfers he finally spoke to a live representative
at Medicare who told him, in all of the twenty cases he billed for
Leprosy.
“Leprosy?”
he yelled at the Medicare representative. “There is no leprosy
outbreak in Canoga Park.”
“I
am looking at the copies of the screen on my computer, and the claims
were all billed with a Leprosy diagnosis.”
“Well
obviously this is just a simple billing error” Dr. Winter’s
proclaimed.
After
hanging up the phone and finding his biller, Dr. Winter’s
determined that his biller had transposed the ICD-9 code and instead
of anxiety using the code 300.0 she had submitted the bills to
Medicare with the code 030.0 for leprosy.
Mr.
Jones was contacted and Dr. Winter’s office had to contact a few
other non-Medicare patients to notify their commercial insurances of
their office’s mistakes. Fortunately, for Mr. Jones he did seek
new employment however his insurance company still shows a history of
Leprosy in the patient’s database of coverage. When he changes
insurances it rears its ugly head again.
The
moral: It is the physician who is responsible to make sure his staff
is accurate especially when submitting claims on his/her behalf. Dr.
Winters was flagged at Medicare and from that day forward he had to
often submit medical records every quarter to justify his level of
billing and for diagnostic accuracy. Over the course of the next
couple of years he got audited by Medicare three times.
