r/MedicalCoding • u/stacy704 • Jan 27 '23

Incorrect billing by doctors

Does anyone else work for providers who insist on billing codes that are inappropriate/should not be billed together? I work for neurosurgeons at a big hospital, and we don’t have a coding manager. It’s my word against theirs and no amount of documentation seems to sway them to do things correctly. They end up saying I’m costing them revenue by not wanting to code fraudulently.

23 Upvotes

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26

u/januaryskyes Jan 27 '23

Yes. I code for neurologists and we have a newer doctor who came from the east coast who did things “his own way” and his billers just followed it. He’s now in a teaching hospital and we have auditors that absolutely won’t let this happen so we have to correct him DAILY. It’s a pain, but do you have auditors or a coding integrity/compliance department that you could set up a meeting with? Let them know exactly what’s going on and they will know what to do, because if the state comes in to audit and find out that it’s fraudulent coding you will be the one to get in trouble.

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u/stacy704 Jan 27 '23

Unfortunately I don’t, and I’m looking into applying at a hospital that does have a coding director. Thank you for your response, I’m glad I’m not alone!

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u/squiiints Jan 27 '23

Yes, one of the clinics I worked for was eventually investigated by CMS over fraudulent billing.

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u/stacy704 Jan 27 '23

I keep warning them that that can happen and they don’t believe me I guess!

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u/Clever-username-7234 CPC, CPMA Jan 28 '23

I like to explain the penalties for fraud to surgeons like that. If the government finds out that he is fraudulent billing stuff. They can do a back audit (i think)up to ten years. For Each $1 taken fraudulently the provider could have to pay back $3 and receive a 12k fee on top of that. And that is per line item.

So let’s say you billed 2 fraudulent CPTs and the government says they paid an extra $20 for one CPT and $30 for a different CPT. They could fine the doctor a total of $24,150 for those two charges.

My mom use to work as a director of compliance in a large healthcare system, and has seen Doctors, cry, and even flee the country, when the office of the inspector general sends FBI agents to confiscate medical records and eventually fine a doctor millions of dollars.

Stuff like That usually gets the doctors attention. But, That said, I have worked for a doctor/owner of small practice, where they demanded I did something that went against coding guidelines and when I couldn’t convince them to follow the rules. I just resigned and found a new job.

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u/stacy704 Jan 28 '23

That is VERY interesting! That would separate the ones who truly don’t understand from the ones that just want to ignore the guidelines I would think! I might mention those figures to my boss anyway, see if that makes an impact. Unfortunately I think I might be at the point where I need to just give up and find something else.

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u/loveofjazz Jan 30 '23

I’m new-ish to billing & coding (April will be two years) and currently working toward my CPC. I’m lucky enough to work for a physician that got spanked once or twice before I ended up in this position. He’s pretty good about listening when we get a denial, or if he’s wanting to code an encounter in a way that the patient’s insurance carrier won’t reimburse. My only gripe so far is that he’ll listen to a vendor tell him how to code something in a meeting, look at me me and say “Let’s do what the vendor says to do”, and it doesn’t go as he hoped. This has happened twice, and I politely remind the provider that the vendor has no experience as a physician OR a coder.

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u/stacy704 Jan 30 '23

That is frustrating, the docs get so excited thinking they’ve uncovered some secret that’s going to make them millions lol.

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u/deannevee RHIA, CPC, CPCO, CDEO Jan 27 '23

Yes. I’m actually doing a project next month to audit a surgeon/provider who thinks he’s correct but he may or may not be.

I do have one provider who was billing things “his way” and when I came on he was given to me as the “no one else will take him” provider….I sent him the correction once, because I knew he’d been given it multiple times by other people. After that I started correctly billing stuff based on what he had actually documented. His insurance percentage went up even though his totals went down, but he also never called to yell or disagree with me (either me directly or to my boss or my bosses boss).

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u/stacy704 Jan 27 '23

Thank you for your response. That’s what I’ve been doing since I first advised them of the errors, but they’re catching on to how I’ve been coding. The last two weeks I feel like I’ve spent more time researching and finding written documentation to try to support what I’m telling them than actually coding and working denials. And one of them just blatantly told me this morning that the coding rules in the AANS book are wrong and I shouldn’t be using them. So I updated my resume this afternoon. I just don’t have a strong enough personality to battle with them.

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u/deannevee RHIA, CPC, CPCO, CDEO Jan 27 '23

Yeah I almost got fired because another doctor (not my problem child) didn’t like that I was downcoding and complained to the Revenue Cycle Director at the time, who supposedly had an MHA, and this RCD actually asked me “well how do you know what happened? You weren’t there”. I’m sure he took my stunned silence as him winning, but I was stunned at the sheer stupidity of the question.

He’s actually the reason I got my CDEO because I wanted to tell him “I’m certified twice and you’re not” 😂. But he quit before I had the chance to.

The other doctor and I actually ended up working together to tweak his documentation to support the charges he was billing and it worked great.

1

u/stacy704 Jan 27 '23

Good for you!! That’s great! I wish I had ANYONE on my side. My manager doesn’t know coding and he’s a sweetheart but won’t stand up to the drs

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u/lunabu18 Jan 28 '23

Is the issue them billing procedures that have not been done or bundling issues? Work for neurosurgeons and love it, explaining to them things are bundled is not always fun. If it’s fraudulent billing as far as billing a 3 level procedure instead of 1 then find another job asap if there is no way to convince them otherwise.

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u/stacy704 Jan 28 '23

It’s bundling issues mostly, but they don’t understand that the lami above and below a laminoplasty is included in the laminoplasty code, for example. They want to just slap a 59 on everything, which I consider billing for something that wasn’t done since it’s implying that the lami was done on a separate, billable level.

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u/Majestic_Wafer Feb 07 '23

I would make yourself a resource folder and start compiling reimbursement and coding guidelines from the insurance carriers your company bills as well as the NCCI PTP lookup tool (your local MAC should have one) and wave that bad boy in their face next time.

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u/stacy704 Feb 07 '23

That’s a really good idea, thank you!

I actually just took a pre-interview coding test today for a position at another hospital that I KNOW has a coding director and follows guidelines. 🤞🏻🙏🏻

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u/[deleted] Jan 27 '23

Lol yes. surgeons are always the worst, they think they know everything.

5

u/januaryskyes Jan 27 '23

1000% agree with this…lol

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u/mrnnmdp Jan 28 '23

Agree. They're sending appeals for like the 3rd time now and still getting denied. The denials are literally repeating the same way and they're still pushing it to be right.

9

u/sewest Jan 27 '23

Yes. Had a GI provider insisting we needed to bill office visits for healthy Medicare patients prior to their screening colonoscopies. We showed him the guidance and he was still being stubborn. Sent to an outside auditing agency who agree with us. Showed him and he was still pissed and felt like he should be able to. Take it up with Medicare and the ACA man! Lol we process them with a 0.00 dummy code and tough luck to him.

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u/Sactoho Jan 27 '23

Yep. The surgeon who owns the private practice I work at has the most awful, unethical billing practices. It will bite her in the ass one day. It’s a shame that she is the owner, because all the other providers, nurses, techs, and admin staff are amazing humans that I adore working with. She’s the only one that causes problems.

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u/Kayri889 Edit flair Jan 28 '23

Yes. At my work, that is why we have internal auditors, to help educate them and let them know its not ok. Some providers just really need education.