I had four messages waiting when I returned from lunch. I’d only been out of the office for a couple of hours, so I was surprised they were all from the same doctor. I could tell right away there was increasing urgency in the doctor’s voice and that he was extremely agitated. Earlier that morning, he unraveled the puzzling events he’d been bewildered by for months. It seemed that a trusted team member was falsifying billing and probably embezzling. He flip-flopped between feeling guilty that he hadn’t been more on top of things and feeling furious over this horrible breach of trust. Where to begin? How deep did this dirty deed go? Unfortunately, when my team and I started digging, it was hip deep. There were services billed that were not performed, money collected that was not theirs, and some money that was completely unaccounted for, and, I feared, stolen. What we have here is both a reimbursement problem AND a compliance problem.
In this case, an onsite visit made the most sense. There was such a mess and a new team member had to be trained. After spending two days deeply involved in analysis and training, I have to say my heart aches for this doctor. He knows where he was culpable…he wasn’t paying attention. He handed over the insurance department to her, rather than delegating it. He didn’t know she was padding bills, hiding money, and having checks re-routed to her home. He didn’t know because he lacked the accountability systems in the practice, and…he wasn’t paying attention. I get fighting mad when I find doctors that have so much trust in their CAs that they simply accept their word as gospel truth. Even if I was your Insurance CA, you need systems.
Unfortunately, this incident crossed the line into a compliance nightmare, because insurance companies were billed as though they were correct services, when in fact they weren’t. And guess whose name was signed to line 31 of the 1500 billing form? The doctor. Once the carriers began investigating, they couldn’t be sure the doctor wasn’t involved. That opened an entirely different can of worms for that doctor. Imagine the devastation he felt! Betrayed by a team member/friend/fellow church member, and then blamed for the heinous act.
I hope you never find yourself in such a situation. But if you do, know what to do about it. Here are some tips:
- Have competent staff; trustworthy staff. But remember, this is your livelihood and your income. Doctors should strive to learn all they can about billing and collections. Know enough to manage them, ask the right questions, and get reports so it appears you are in the game.
- Implement systems that allow for checks and balances. A simple end-of-day balancing form was put into service that forced the CA to total money, routing slips, and patients, and balance to the penny. Those were reviewed by a third party, and then turned in to the doctor. Not fool-proof, but markedly better than nothing. Other compliance related activities were easy to implement for peace of mind.
- If you find that overpayments have been received, or embezzlement has happened, you have a very short time to refund the money. In the case of Medicare, only 60 days. That means you should be self-auditing on a regular basis. The OIG Compliance rules say you have to. Don’t leave this to chance. You don’t want to find out something is amiss only after you’re audited by an outside source. Self-auditing and self-reporting are a much better plan.
Our staff can be like family, and rightly so. It’s easy to be lulled into a false sense of security. Systems, compliance programs and checks and balances installed in the practice will help to make sure you never have to suffer this unspeakable nightmare.
Kathy Mills Chang is a Certified Medical Compliance Specialist (MCS-P) and since 1983, has been providing chiropractors with reimbursement and compliance training, advice and tools to improve the financial performance of their practices. Kathy can be reached at 888-659-8777 or