It is sad to say but fraud seems to be everywhere today.  This was a scheme on the internet where people were lured into a “billing at home”business so a word to the wise no matter which side you are on, the billing or the provider side, make sure you are dealing with reputable people and companies.  EDI Healthclaims was the name of the business that settled with the FTC and the Department of Justice.

The reimbursement is for the money paid up front by an individual to get started with their business.

This week, an administrator working on behalf of the Federal Trade Commission mailed checks to 3,500 consumers nationwide who were defrauded by a group of marketers accused of hawking phony business opportunities. Consumers who were victims of this scam will receive a total of $95,000 in redress

The reimbursement stems from the February 2008 settlement of a case brought as part of a Commission-led law enforcement sweep that included more than 100 actions filed by the FTC, the Department of Justice, the U.S. Postal Inspection Service, and other agencies in 11 states. In this case, known as EDI Healthclaims, the FTC alleged that scammers used mass mailings to consumers offering a “work-at-home” business opportunity to earn easy money electronically processing health-care providers’ medical claims for insurance reimbursement.

 http://www.consumeraffairs.com/news04/2010/05/ftc_medical_billing.html

In the news lately with healthcare reform is also a crack down on billing fraud.   It happen everywhere with both Medicare and Commercial insurers.  Sometimes it is not caught until the patient ends up finding it on their tab.  Listed below are a couple examples of some pretty high bills found by patients themselves that are not related in any way to any condition they might have.

Efforts are being stepped up to use technology to audit and evaluate claims for potential fraud.  Sometimes the crooks do such a good job with accuracy, they get paid faster and sooner than providers.   In the next few years you can expect even more inquisitions as the government steps up their efforts to defeat fraud.  One of the biggest areas has been equipment fraud with wheelchairs and other items that are billed for patients who do not need them and in most of these cases the individuals committing fraud are just looking for a provider and patient name to bill.

March 23 (Bloomberg) — Sierra Morgan was billed $12,000 on her health-care credit card in November for liposuction, a procedure she never requested or had.

“It’s depressing to know that someone used my name and knows so much about me,” said the 31-year-old respiratory therapist from Modesto, California.

There were more than 275,000 cases in the U.S. last year of medical information theft, twice the number in 2008, according to Javelin Strategy & Research, a Pleasanton, California-based market research firm. The average fraud cost $12,100, Javelin said.

 Brandon Sharp, 38, found more than $100,000 of unpaid medical bills on his credit report when he went to buy a home. The charges included $19,501 for a life-flight helicopter trip and emergency room visits he never used, said Sharp, a project manager for an oil company in Houston, Texas. “I’m as healthy as they come,” he said.

 http://www.businessweek.com/news/2010-03-23/patient-billed-for-liposuction-as-medical-theft-rises-update1-.html

Medical billing is one area that represents constant change.  If it is not the insurance carriers, we have new provisions with Medicare to keep on top of, such as no consultation code with Medicare.  If you are providing medical billing services to clients, this meeting could be one you might want to put on your calendar.

It is coming up next month and will be held in the Washington DC area.  Listed below are some of the topics on the agenda to include the new HIPAA laws, which do including billing and business associates.

To learn more or register for the HBMA 2010 Compliance Conference, visit HBMA’s event page.

 Press Release:

Annual Event Will Help Medical Billing Professionals Develop and Assess Compliance Plans against the Backdrop of Federal Legislation and Regulatory Concerns

LAGUNA BEACH, Calif.–(BUSINESS WIRE)–The Healthcare Billing & Management Association (HBMA), a non-profit educational resource and advocacy group representing third-party medical billers and billing professionals, today announced details of the association’s 2010 Compliance Conference. Taking place at Hotel Monaco in Alexandria, Va., March 9-11, HBMA’s Compliance Conference will help participants to gain deeper understanding of many issues relating to compliance within the healthcare billing industry.

Andrea L. Treese Berlin, senior counsel for the U.S. Department of Health and Human Services, Office of the Counsel to the Inspector General, will be on hand to speak to attendees on OIG-specific compliance issues. Additional conference sessions will include discussions on such critical compliance areas as:

• HIPAA, HITECH and other federal regulations
• Billing company policies and procedures
• Effective monitoring and auditing
• Coding education and training
• Risk assessments
• Billing contracts and negotiation
• On Wednesday, March 10, the conference features a presentation by Attorney Mark Cunningham, titled, “How to ‘Date’ Your Client.” This session offers participants advice ranging from problem areas in client-billing company relations, to issues and recommendations for building a strong relationship with a client. A post-conference session called “Hot Topics in Compliance” will be held on Friday, March 12 and hosted by Louie; Karen Collier, Esquire; Jackie Willett, CHBME and Bob Burleigh, CHBME. This session will address major topical compliance concerns such as human resources, RAC, successful ALJ appeals, ICD-10, enforcement, coding, quality payments and several other industry topics of interest and concern to participants.Conference registration opens at 11:30 a.m. on Tuesday, March 9, and includes a comprehensive schedule of sessions, networking lunches, informal activities like “Compliance Jeopardy,” an evening reception, and a tour of the D.C. area. Bill Finerfrock, HBMA’s legislative consultant from Capitol Associates, will present his “Washington Update” in a Wednesday, March 10 session.

The full press release can be read at the link below:

http://www.businesswire.com/portal/site/home/permalink/?ndmViewId=news_view&newsId=20100208006133&newsLang=en

 Here’s a brief summary of what to expect and which codes to use.  There has been no word yet from commercial carriers on what their position will be with the provisions.  This is something to give some consideration if Medicare is the secondary payer on claims as you may end up with a denial on the Medicare portion due to the change of coding.

1. Consultation codes 99241-99245 (outpatient/office) and 99251-99255 (inpatient) have been eliminated. Tele-health consultation G-codes (G0425-G0427) will not be eliminated.

2. Use codes for new (99201-99205) or established (99211-99215) patients to replace consultations in the office/outpatient setting.

3. Codes in the inpatient hospital setting (99221-99223) should be used to replace inpatient consultation codes (99251-99255), and for nursing facility consultations use codes (99304-99306).

4. To distinguish the difference between the admitting physician of record from the consultants for initial hospital inpatient and nursing facility admissions, Medicare will develop a modifier. Check with your local carrier for more information.

5. Payments for all Evaluation and Management codes have been increased in an attempt to offset the fees lost from the elimination of consultation codes.

The full article can be read at the link below.

 http://ezinearticles.com/?Medicare-Eliminates-Consult-Codes—What-Now?&id=3370768

 One big important change is the use of past billing records, this is being done to help combat fraud and errors.  One other item worth mentioning is the fact they now want legible signatures, which might be a challenge to some.  Durable medical equipment must also be properly documented.

A Medicare initiative to better calculate fee-for-service payment error rates will result in new billing procedures for hospitals. The program also is reporting a much higher error rate than in past years.

The Centers for Medicare and Medicaid services has revamped how it reviews Medicare claims for inpatient hospital services and has eliminated the use of past billing records as part of a complex medical review. The result of heightened scrutiny and a more complete accounting of fee-for-service claims is that Medicare’s 2009 FFS error rate was 7.8%, compared with 3.6% in 2008, according to CMS.
More information is available at https://www.cms.hhs.gov/apps/media/press_releases.asp and https://www.cms.hhs.gov/apps/media/fact_sheets.asp.

http://www.healthdatamanagement.com/news/billing-39385-1.html?ET=healthdatamanagement:e1085:120588a:&st=email