Have You Ever Been Accused of Improper Billing by a Staff Member?

by Marty Kotlar, DC, CPCO, CBCS

Question:  I have been accused of improper billing by a staff member. I am very concerned about this. Am I going to get investigated? Are there any steps I can take to protect myself?

Answer:  If you ever get accused of improper billing by a staff member, you should have an action plan in place. To begin with, all staff members should have a means to effectively report observed instances that could be potential billing and coding violations.                                                       

Yes, there is a chance you can get investigated. Employee billing and coding concerns should be taken very seriously. If you do not know how to respond to an investigation, you may end up making things worse without realizing it. I have seen it happen many times. Contact a professional coder that specializes in board complaints, investigations and chiropractic billing for assistance.

I was recently hired by a doctor to assist him with an unfortunate situation. He had a staff member suddenly resign and on her way out the door, handed the doctor a scathing resignation letter. It stated “I can no longer continue to take part in the unethical and often illegal practices this office takes part in. A doctor cannot simply make up an amount and charge patients whatever they want. That is fraud. I expressed concerns over submitting claims to insurance for all of the patients with the same ICD codes. This is also illegal. There is also a disregard for the proper documentation. I brought this up and it was brushed off.”

Wow, that should get your attention. This staff member can do a lot of damage to this doctor’s reputation and possibly report him to the state board and compliance investigators. If a billing concern arises, they must be reported and reviewed by the billing supervisor or business owner. Hopefully you’ll never have to deal with a problem like this again, however it’s good to know what to do just in case.

Make sure to maintain the confidentiality and privacy of the person reporting the concern or potential violation. In a small practice setting, it may be impossible to keep reported concerns anonymous, therefore if an employee would like to submit an anonymous report, include this information in your billing policy manual and you may want to have the employee mail a typed letter describing the concern in an envelope without a return name/address.

You should protect any person filing a concern from retaliation. If someone is retaliating in any manner against another employee as a result of the compliance concern submitted, the observing individual should immediately notify the billing supervisor or business owner. When an employee observes a potential compliance violation and does not report the incident, non-reported observations, if discovered, could be grounds for termination. 

You should have a system for investigating compliance concerns. Start with this approach:

• any allegations of suspected improper or illegal activity should be reported to the billing supervisor or to the business owner.
• the billing supervisor or business owner will review the information and make a determination if a violation has indeed occurred.
• if no violation has occurred, the billing supervisor or business owner shall document the findings and communicate the findings to the individual making the allegations and provide training to the individual so they may understand why the suspected violation was not an actual violation.
• if the billing supervisor or business owner determines that an actual violation may have occurred, the billing supervisor or business owner shall document his/her findings and contact legal counsel (if necessary) to determine the appropriate course of action. The course of action may include but not be limited to the following reporting of the incident to the applicable government payer, voluntary disclosure to the OIG, refund of overpayments to the applicable payer (if necessary).

Regardless of the result of the findings (actual violation or a non-violation), all allegations reported to the billing supervisor or business owner shall be documented. Also, create an Employee Billing Concern Form. This is used to formally document the details of the complaint. If you’d like to receive a copy of this form, send an email to info@targetcoding.com.

Dr. Marty Kotlar is the President of Target Coding. Over the last 12 years, he has helped hundreds of chiropractors, acupuncturists, physical therapists and massage therapists with compliance as it relates to billing, coding, documentation, Medicare & HIPAA. Dr. Kotlar is certified in compliance, a certified coding specialist, a contributing author to many coding and compliance journals and a guest speaker at many state association conventions. He can be reached at 1-800-270-7044, website – www.TargetCoding.com, email – drkotlar@targetcoding.com.