Avoid Audits: Make Sure Your Medical Billing Practices Are Above Board

August 28, 2014

In light of continuing Medicare fraud, it is vital to review your coding and billing procedures. Prevention is key to avoiding expensive take-backs.

Recently, the U.S. Attorney's Office for Northern District of Ohio unsealed a 16-count indictment charging Dr. Harold Persaud of healthcare fraud and "monetary transactions in property derived from criminal activity." There are several notable aspects of this case. First, the billings were not limited to Medicare. The unnecessary catheterizations and other cardiac related procedures were billed to other insurers, too. Second, patient records were falsified. And third, the FBI brought in a property aspect to the criminal charges.

Special Agent, Stephen D. Anthony indicated that this case is particularly egregious because of the violation of the patient-doctor relationship. This relationship is based on a fiduciary obligation owed by physicians to their patients. The fiduciary responsibilities include doing what is in the best interest of the patient, providing only necessary services, and reducing the risk of harm. Not only was the Hippocratic Oath violated, taxpayers and other insurers were financially harmed, too.

Over a six-year period, the illicit activities, as set forth in the indictment included:

• Selecting a billing code that reflected a service that was more costly than that which was actually performed, for each customer submitted to Medicare and private insurers;

• Performing nuclear stress tests on patients that were not medically necessary;

• Knowingly recorded false results of patients' nuclear stress tests to justify cardiac catheterization procedures that were not medically necessary;

• Performing cardiac catheterizations on patients at hospitals and falsely recording the existence and extent of lesions (blockage) observed during the procedures;

• Recording false symptoms in patient records to justify testing and procedures on patients;

• Inserting cardiac stents in patients who did not have 70 percent or more blockage in the vessel stented, and who did not have symptoms of blockage;

• Placing a stent in a stenosed artery that already had a functioning bypass, thus providing no medical benefit and increasing the risk of harm to the patient;

• Improperly referring patients for coronary artery bypass surgery when there was no medical necessity for such surgery, which benefitted Persaud by increasing the amount of follow-up testing he could perform and bill to Medicare and private insurers; and

• Performing medically unnecessary stent procedures, aortograms, renal angiograms, and other procedures and tests.

Dr. Persaud's actions caused the overbilling of Medicare and private insurers in the amount of approximately $7.2 million, of which Medicare and the private insurers paid approximately $1.5 million.

This case highlights the ongoing need for compliance and the focus on patient care. Now is a good time to evaluate your current practices and procedures, to make sure none of the items that appear in the indictment are even suspected in your practice.