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False Claims Penalties: How urgent cares can lower the risk and stay compliant.

Aug 6

False Claims Penalties: How urgent cares can lower the risk and stay compliant.

2018 | Filed in

Business is booming. Urgent care clinics are becoming a top choice for many patients seeking on-demand medical care and as an alternative to the emergency room. In fact, a recent FAIR Health Report suggests that from 2007 to 2016, urgent care centers showed an increase in claim lines of 1,725 percent, far surpassing the growth in ER claim lines during that same period.

What that means for urgent cares is more patients—and more claims. Processing an increasing number of claims can be a challenge for clinics without a billing service, not only because of the volume, but also because private payers have different policies and guidelines that can be confusing and hard to keep up with. While many payers follow CMS (Centers for Medicare and Medicaid Services) guidelines, regulations can vary by state and payer.

The biggest challenges to compliant billing for urgent cares are ensuring all providers are properly credentialed and that claims involving non-physician care providers are handled and coded properly according to the Federal False Claim Act (FCA)

What constitutes a false claim?

According to the False Claim Act, it is a crime for any person or organization to:

  • knowingly presenting, or causing to be presented, a false or fraudulent claim for payment or approval;
  • knowingly making, using, or causing to be made or used, a false record or statement material to a false or fraudulent claim;
  • conspiring to commit a violation of the Federal False Claims Act; and
  • knowingly making, using, or causing to be made or used, a false record or statement material to an obligation to pay or transmit money or property to the Government, or knowingly concealing or knowingly and improperly avoiding or decreasing an obligation to pay or transmit money or property to the government.

 States also have additional rules and regulations that may apply. While incorrect or fraudulent billing may not be the intent of a provider or clinic, without careful oversight and expert billers, the risk of non-compliance—and the cost of litigation—is high.

According to a recent report released by the Office of the Inspector General (OIG), Medicaid fraud control units (MFCUs) recovered $1.8 billion in 2017 in cases involving fraud and patient abuse.

In February of 2017, the FCA raised the monetary penalties for submitting false claims from a minimum of $10,957 to a maximum of $21,916 per claim.

Some examples of false claims are billing for services not provided, billing for the same service more than once, making false statements to obtain payment for services, and improper use of a National Provider Identifier (NPI) by mid-level and other providers.

To facilitate quicker reimbursement, it can be tempting for urgent care groups to submit claims under a credentialed physicians name while the rendering physician has not been credentialed by a specific private payer. This constitutes a false claim under the law. It is prudent (and legal) to hold claims until credentialing is complete.

How can you lower your risk and stay compliant?

According to our Compliance Officer, Phyllis Dobberstein, there are steps you can take to make sure you stay compliant.

1. Make compliance and credentialing top priorities.

While the main purpose of your medical practice is medicine and patient care, a good amount of emphasis must be placed on credentialing, proper billing, and accurate coding. It can’t be an afterthought. With changing contracts and controls by payers, it’s essential to designate someone or, based on the size of your practice, multiple people to be responsible and accountable for keeping your billing on track. These clinic experts should understand the correct use of NPIs for practitioners and caregivers at every level. Don’t wait until you get dinged to pay attention.

2. Understand federal guidelines.

According to federal guidelines for Medicare and Medicaid, every provider must be individually credentialed with all services billed under the rendering provider. Be sure everyone who touches a claim or billing documentation understands these and all regulations around compliance that could result in false claims.

CMS and most payers also provide for Incident-to billing for some claims. This is a method of billing for incidental services performed by non-physician practitioners and non-physician employees in accordance with the physician’s treatment plan. This situation is uncommon in the urgent care setting.

There are generally two instances in which a physician can legally bill under the NPI of another physician with the appropriate modifier: reciprocal billing arrangements and fee-for-time compensation arrangements. (Learn more. Download our compliance coding guide here.)

3. Read every contract.

Outside Medicare and Medicaid claims, the process can get more confusing. Private payers are not required by law to meet the same CMS guidelines, but contractual billing requirements may vary based on state guidelines and other factors.

There is risk in not following contractual requirements—the payer may recoup what they reimbursed you, or you could lose the contract altogether. Be sure you have an experienced professional go through all payer contracts so everyone on your billing team understands any subtle differences that apply.

4. Educate your billing team.

Your billing team is your revenue lifeline. Every person that is involved in the billing and claims processes must know federal requirements and the requirements of each payer. To mitigate risk of false claims, they must have a thorough understanding of regulations, pay attention to details, and insist on accuracy for every claim. 

When you follow these important steps, you will lower your non-compliance risk. But there are other positive results. One of the biggest benefits to submitting clean, and compliant claims is that you will optimize reimbursements for all the work you do making your practice more profitable.

Get smarter about compliance. How to Avoid FCA Penalties: A guide to compliant coding