The submission of any incorrect claims to payers can result in severe negative consequences. The Hospital or Clinic is committed to preventing and correcting billing errors. The False Claims Act penalize billing fraud, waste and abuse. The best time to ask questions about billing, coding and documentation issues is before any claims are submitted. Any employee who knows or is concerned that billing errors are occurring has an obligation to report the issues to leadership, your supervisor or the compliance officer.
Real-world scenario
Q: We are going to begin using a new, innovative medical device to treat patients. The sales representative for the manufacturer suggested a CPT code to use that he/she said always gets paid by the payer. Can we use the CPT code?
A: The appropriate CPT code to use should be researched and vetted BEFORE any claims are submitted. Just because a device exists or has FDA clearance does not necessarily mean a CPT code has been assigned and payers have approved it for payment. Using another code that is not specific to the new device may result in false claims.
Q: I work in the billing department and have noticed that the remittances or EOBs from payers for a certain service include an error code and a denial. Should I be concerned?
A: It depends on the specific nature of the business and the terms of your agreement. You should consult with hospital/clinic administration or have the agreement and circumstances reviewed by an attorney. If the investment also involved your active participation in the management or operation of the business, you would need to make sure it did not interfere with your duties to the hospital/clinic.
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McAfee &Taft provides this complimentary monthly compliance checkup as a resource for compliance officers and others filling a compliance role — something that can easily be forwarded to employees, with or without modification, for compliance program training. These include a provision similar to a typical compliance program with a typical scenario/question and the resolution/answer.
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