Deeper Than the Headlines: Health System To Pay $671,300 To Resolve Improper Billing Allegations Related to the False Claims Act



Hey everybody. This is CJ Wolf with Healthicity.

Today, we're going to share with you a little bit of information from our deeper than the headline series.

The intent of the series is to go a little bit beyond what you might see in a Department of Justice press release or an OIG announcement that, you know, physician office x or hospital y, settled for this amount of money for the following, you know, general reasons. And we see that a lot in some of these press releases.

And so they start to all these press releases all start to sound the same and read the same you don't you don't get a lot of the flavor or the color of what really might have gone wrong. So the one case I wanna talk about today was has to do with incident to billing.

For those of you who don't know, I'll just very briefly describe that incident to billing is when a physician, assistant or nurse practitioner, for example, might be working with a physician in a group practice.

And there are two ways to bill for those services. Physician assistants, nurse practitioners can bill in their own name. They have your own billing provider to Medicare, assuming they've they've gone through that, credentialing process and application process. So they can bill in their own name for their services.

Medicare reimburses at a lower rate than if services those same exact services were billed in the name of the physician. So a lot of practices organizations want to build that higher rate, of course. But to do that, you have to meet certain criteria. So and to meet those criteria, that those criteria are called incident two billing or incident two guidelines. And and Medicare says that in order for services to be billed as incident to and to be covered at that higher rate. There has to be a direct personal professional service furnished by the physician that initiates the course of treatment, of which the service being performed by the non physician, nurse practitioner, PA, is an incidental part.

And there must be subsequent services by the physician of a frequency that reflects the physician's continuing active participation in and management of the course of treatment. So basically if a patient comes in with a new problem, the physician has to see that patient establish the plan of care and then maybe that plan of care is four or five days or four or five weeks of care.

That's the subsequent visits could then be, performed by the PA or the nurse practitioner under this this plan of care or this treatment plan that the physician is set up and without the physician even seeing the patient in those subsequent visits, those services can be billed in the physician's name and get this higher rate, assuming certain criteria are met.

And if those criteria are not met, you're over billing.

And you should have billed in the physician's assistant's name or the nurse practitioner's name. So the case this particular case comes from the state of Michigan where a health system agreed to pay over six hundred and seventy thousand dollars to resolve allegations that, they were inappropriately billing under the incident to rule. And there's not much more said in the press release. So what I did is I looked up the court records.

I went and I found the complaint that's filed by the whistleblower. This case was a whistleblower case. Remember under the false claims act, a whistleblower can can file the case, and they can get a percentage of of any recoveries. So there's this incentive for financial incentive at least for whistleblowers to do this.

Now the whistleblower in this case was a physician and that physician actually was a, medical director for this, organization for the medical group, at least, a member of the medical group and a, board member of that medical group, and then also served as a quality and safety committee board member. So interesting and a couple examples that they actually give in the complaint include, and and hopefully this is where we're adding some color and some value for you here.

The complaint states that in the course of the reviews that this, physician does as, you know, as a member of the board, as a member of the, quality and safety committee. This individual physician has seen a lot of records and and seeing some of the billing that might be going on.

And what I'll give you one example here of where this went awry. The the there was an example of a physician assistant who conducted an initial evaluation of a seventy three year old Medicare patient who's complaining about pain in the knee.

Nothing wrong with that. Right? PAs can do that all the time, and they can bill in their own name. But to bill in the physician's name, it has to be incident to a plan of care that physician established, and what the notes identified in this particular case was that in this particular example of this case, was that the physician assistant documented that they were seeing a new patient, and the examination was for an initial evaluation the right knee planes of right knee pain.

So that that note, clearly demonstrated that the physician was not really involved in that treatment plan. Right? And they don't have to be if you're going to bill in the physician assistant's name, but if you're going to bill in the physician's name, then you have to meet these incident to guidelines. It also goes on to say that in this in this example, with this patient, that two months later, the same physician assistant conducted a follow-up of exam.

Both services that initial one and the follow-up were billed as incident two in that physician's name for that higher reimbursement amount.

But the chart itself did not show that the doctor was caring for examining or developing a treatment plan for that patient. And then another example, there's many examples from from these court records, but I just wanted to share a couple to give you a flavor of of what we see, beyond just the headline here.

Over a two year period, both a nurse practitioner and a physician assistant independently examined and treated an eighty nine year old medic patient, three different times. And all three visits were billed incident too, meaning build in the physician's name.

The physician though, the only thing in the chart, was that that the physician stated they reviewed the notes, they reviewed the assessment, the order and or the procedures performed by the physician physician assistant nurse practitioner, and then noted in the chart that he concurred.

The chart does not say that the doctor performed the examination, developed a treatment or management care plan on that initial or follow-up visit. So gotta be careful here. These are really good examples, though, of where you could go, awry, or you could have some missteps as it relates to incident to billing.

Hopefully, this has been helpful to kinda give you a little bit more color beyond just the headline of, in this case, know, health system pays six hundred and seventy thousand dollars to resolve, allegations of misuse of incident to billing rules. Thanks for listening. Hope to have you listen again to our next episode of deeper in the headlines.

Thanks for listening. We hope you will listen again for our next episode of deeper than the headlines.

(Please forgive any spelling or grammatical errors. This transcript was auto-generated.)

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