Before representing a defendant charged with health care fraud, it is important for defense counsel to gain a detailed understanding of Medicare billing. Many criminal defense attorneys who are not well-versed in Medicare and Medicaid or private insurance billing may struggle with these complex concepts.
Prior to billing Medicare, Medicaid, or a private insurance company for a service, the physician or practice must be credentialed by the insurance entity. Generally, credentialing requires certification that the physician or practice will comply with federal rules and regulations as well as the policies of the insurance company.
Medicare’s rules and regulations are incredibly detailed and complex. Center for Medicare Services (CMS) regulations, as well as local and national coverage determinations (LCD and NCDs, respectively), define what Medicare will reimburse. The government often indicts physicians and practices for charging for services that were either not medically necessary or rendered in violation of regulations or LCDs and NCDs.
When an eligible provider performs a service for a Medicare beneficiary, the service is reduced to a code which corresponds to that service. There are three common types of codes: Current Procedural Terminology (CPT) codes; Healthcare Common Procedures Coding System codes (HCPCS); and International Classification of Diseases, 10th revision, Clinical Modification codes, also referred to as ICD-10.
CPT codes describe how to report procedures, while HCPCS codes are used to report supplies, equipment, and devices provided to patients. HCPCS is alphanumeric and administered by the CMS.
ICD-10 codes are used to report diagnoses and disorders, and this coding system is maintained and revised by the National Center for Health Services (NCHS).