I’ve spoken with lots of providers whom I feel are not billing properly, either due to ignorance or sometimes deliberately attempting to get more money from an insurance carrier. When I explain billing and coding and exactly what they are doing that is incorrect, the usual response is: “Well the insurance company is paying, why should I change?” You know what – They’re right in that the insurance carrier usually is paying and quite well too, however what they do not realize is the information about those services they billing for can be requested AT ANY TIME by the insurance carrier. The carrier has the right to request medical records to substantiate the need for the treatment long AFTER the claims have been processed and paid.
The following are three situations I see frequently that can come back to haunt a provider:
1. Billing for an office visit EVERY single time they see the patient. This is by far the biggest NO-NO, and carriers are catching on. There must be a substantiating need for a separate office visit, and that can’t happen two to three times a week.
2. Billing for a timed procedure that was only done for a short amount of time or not at all. By far the biggest culprit is 97140, myofascial release. The rule is you must provide the service for at minimum 8 minutes to bill 1 unit of a timed based code. Giving the patient a 2 minute neck massage is not going to cover it. Did the procedure but didn’t document the time on your notes? Get audited and you’re giving the money back.
3. Never changing a patient’s diagnosis. I’ve literally seen patients that have been treated for years for the SAME condition. Again the provider will say – well they keep paying. This creates two conditions. Either: A. You are treating the patient and he is NOT GETTING BETTER! Or B. You are treating the patient for one thing, but submitting a claim for something else. The carrier requests the notes and/or sends a questionnaire to the patient, either way, and you’re going to be asked for the money back.
Audits, requests for records, are NOT GOING AWAY. Mark my words – if you have been doing any of these three things, it’s only a matter of time before it comes back to haunt you, and I don’t want to say, I told you so.