Medical Provider Check-Ups: Do it Now

November 30, 2015Articles Garden State Gavel Blog

Given the heightened scrutiny that abounds to uncover insurance fraud in the Garden State, medical providers need to conduct internal and external “check ups ” to protect their practice and their reputations in the event of a payor audit, investigation or litigation.

In New Jersey, there are a variety of ways that a medical practitioner can be targeted for an investigation. For example, a private payor may randomly review a provider’s billing forms and notice the use of a certain code that may be inappropriate for the service provided. This discovery may lead to an investigation by a member of the payor’s “Special Investigation Unit” (SIU).

Once the SIU is involved, an investigator may forward correspondence demanding a review of patient records or worse, come knocking at your door and demand access to them. Typically, the SIU will conduct an audit of sample files and extrapolate an overpayment demand. The SIU will often claim that the wrongful billing amounts to a violation of New Jersey’s Insurance Fraud Prevention Act (the “Act”) and threaten that the failure to meet the overpayment demand will be met with litigation under the Act.

In some cases where the SIU suspects fraud, it will refer the matter to the Bureau of Fraud Deterrence (“Bureau”) and the State will become involved in the investigation. A Bureau investigator may meet with the provider, interview staff and request records. The investigator may already have the private payor’s investigatory materials to assist in the investigation process. If the Bureau finds an issue with respect to inappropriate billing or other coding violations, it will require the provider to sign a consent order acknowledging the error and impose additional fines.

Separately, a private party (“whistleblower”) can institute a “qui tam” action against a provider for suspected fraud under New Jersey’s False Claims Act (“NJFCA”). Once a NJFCA complaint is filed, the State can investigate the claim and determine whether to intervene in the NJFCA and prosecute the matter. The whistleblower receives a percentage of the monetary recovery in these cases which can amount to a substantial sum.

More often than not, providers are so busy taking care of patient needs that they neglect their own. Providers must be educated on the latest trends in billing, the codes that are under scrutiny, and ever- changing federal mandates and private payor bulletins that impact how the provider can bill for services. And while many providers seek comfort in engaging a billing company to navigate the coding waters for them, it is not enough. The billing company may not be on top of these significant changes and may be relying upon a computerized system that does not scrub for billing inaccuracies.

Check- up List:

  1. Conduct a random audit of files and claims. If you are not 100% sure that you are on top of all of the latest coding requirement and details, engage a consultant to assist in the process.

  2. Educate yourself on the particular codes that govern your practice and look for changes or updates to the utilization of these codes.

  3. Check in with your billing company to determine what it is doing to assist you in ensuring that there are no billing irregularities. What system is it using? How is it looking out for your practice? Has the company had issues in the past? Does the company employ certified coders? Ask the important questions.

If an investigator contacts you, seek out an attorney with experience in this area.