Improper Coding Could Lead to a Criminal Conviction and Exclusion

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As the federal government is casting a wider net to detect and prosecute fraud in the medical industry, the question is not if your medical billing and coding will come under scrutiny, but when.

Medical billing and coding is translating what medical procedures were performed and why. Coding amounts to a language of numbers and letters that are unique to the medical field. 

Each claim is a communication between a medical provider and federal health program, such as Medicare, Medicaid, or TriCare. Whether the claim is filed on paper or electronically, each claim for outpatient services includes the following certification:

“In submitting this claim for payment from federal funds, I certify that:

    1. the information on this from is true, accurate and complete;
    2. I have familiarized myself with all applicable laws, regulations, and program instructions, which are available from the Medicare contractor;
    3. I have provided or will provide sufficient information required to allow the government to make an informed eligibility and payment decision;
    4. this claim, whether submitted by me or on my behalf by my designated billing company, complies with all applicable Medicare and/or Medicaid laws, regulations, and program instructions for payment including but not limited to the Federal anti-kickback statute and Physician Self-Referral law (Stark Law);
    5. the services on this form were medically necessary and personally furnished by me or were furnished incident to my professional service by my employee under my direct supervision, except as otherwise expressly permitted by Medicare or Tricare;
    6. for each service rendered incident to my professional service, the identity (legal name and NPI, license #, or SSN) of the primary individual rendering each service is reported in the designated section.”

This certification is an assertion that all criteria are met and that to the best of the medical provider’s knowledge, the services are payable. This statement does not leave much to question.

… Or does it?

Conditions of Payment

“Conditions of Participation” refers to the requirements of participation in a federal health program. Before a medical provider can receive payment from a federal health program such as Medicare, Medicaid, or Tricare, they must apply for “participation.” This process involves filling out applications and submitting documents, to show licensure or accreditation. The conditions may also require certain levels of liability insurance or for medical providers to hold certain certifications.

Because this information is provided at the time of applying for participation and not continuously, it is possible that a medical provider may fall out of compliance after receiving participation status.

In addition, accreditation is a condition of participation. For example, radiology providers who perform Advanced Diagnostic Imaging (ADI) (ex: MRI, CT or PET scans) for Medicare patients in freestanding facilities, must hold specific accreditation from the American College of Radiology (ACR), the Intersocietal Accreditation Commission (IAC), The Joint Commission (TJC) or RadSite. Each one of these accrediting organizations has requirements or conditions for accreditation to be awarded.

Different false claim actions have been brought against providers who failed to comply with these conditions of accreditation, after the accreditation was awarded. If the medical provider is out of compliance with the accreditation organization requirements, it would follow that the medical provider is out of compliance with the requirements of the conditions of participation with the federal health program. If the medical provider is out of compliance for participation, payment should not be made to the provider.

In addition, the certification attested to on the claim form is a false statement, because the medical provider is stating that they are in compliance with “laws, regulations and program instructions.” Although this is a far-reaching concept, it has arisen in whistleblower actions that require legal defense.

Make the Right Choice in a National Healthcare Attorney for Coding Disputes: The Chapman Law Group

Finding a healthcare-oriented criminal defense attorney should be done under careful consideration. Counsel must be proficient in the descriptions and implications of specific CPT and ICD-9/ICD-10 codes. 

Physicians and other medical provider must ensure that lawyer speaks their language. Knowledge of correct coding, medical terminology, and credentialing is essential to providing quality representation to health care providers. You can be assured that the federal government’s attorney is skilled at interpreting the alphanumeric coding language of the medical industry.

Because we only focus on the healthcare sector, we at Chapman Law Group are well-versed in medical billing and codes, the credentialing process, and the process for medical providers to become eligible to participate in federal health programs. We have worked with many doctors offices, pain care management, regulated facilities, dentist and ophthalmologist offices, and other healthcare practitioners across the U.S. on these types of matters.

For more than three decades, we have provided top legal service for licensed healthcare professionals throughout the country. Our four national healthcare defense law offices are in Detroit, MiciganMiami and Sarasota, Florida; and Los Angeles/Southern California

Contact us today for a consultation.

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Summer McKeivier


Healthcare-Based Criminal Law, Healthcare Fraud

Los Angeles Office

5250 Lankershim Blvd., Ste. 500
North Hollywood, CA 91601
Phone: (248) 644-6326

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