As I travel around and meet people inside and outside of healthcare as a consultant, I’m always struck by how many processes people follow that aren’t only outside the norm, but could possibly put a facility in danger of being accused of fraudulent practices. Sometimes employees start doing something because it helps them get around an issue they ran across, yet didn’t want to bother anyone about. Sometimes they were told something that was specific to one issue, and they take it and run with it for many other issues. It really doesn’t matter how employees start doing something; what matters, from my compliance background, is that someone figures it out and gets a handle on it as soon as possible, to help minimize the damage possibly done.

Do you know what everyone is doing? I’ve talked about something like this before when I mentioned meetings. Meetings won’t tell you the entire story, though. If someone is doing something they don’t know is incorrect, it may not come up in a meeting. I’m going to point out a couple of things that you may want to look out for. How do you catch it? Ask people if they’re doing any of these things.

1. Coding issues. I remember a facility I went to where, sometimes, insurance companies would deny a claim saying the diagnosis claim didn’t fit the procedure code. So what some of the billing personnel would do would be to go looking through past bills that were submitted for a diagnosis code that more closely associated itself with the procedure that was performed on their particular bill. On the surface, I could see where this might make sense to a biller. However, as we all know by now, this is a fraudulent action, not because it may not be right, but because the method for obtaining the correct code is incorrect. Diagnosis codes may look similar at times, but there’s enough nuances that make it imperative to verify exactly which diagnosis code should be there.

It’s also important for another reason; it’s possible that the wrong charges went onto the wrong account. Either that patient wasn’t there on that day, or the wrong charges were put onto that patient’s account because someone mixed up the account numbers. Yet that patient had been in your facility in the past for something similar, so a diagnosis code was found that somewhat matched the service.

Either way, it amounts to someone in billing changing codes with the intention of trying to get a claim paid, not trying to make sure an accurate claim was submitted. That’s pretty much the definition of fraud, whether they know it or not.

2. Itemized statements and bills. Insurance and self pay follow up can be frustrating at times; I know because I’ve had to do it. There are times when you feel you can’t get any answers from anyone, yet you’re the one charged with trying to get some kind of payment on a claim. Sometimes your mind leaves you and you do something without really thinking much about it, while trying to achieve your main objective, which is getting the claim paid. That’s when the business office can run into problems.

One problem is sending claims to people who aren’t supposed to receive them based on their insurance type. I don’t know if this is across the board in every state in the nation, but in many states you can’t send a bill for payment to anyone who’s on Medicaid that’s been verified, compensation that’s still being reviewed, or an insurance company that’s yet to make a final determination on a claim. I have heard of ways facilities have tried to get around these rules, and I’d have to say they’re pretty sneaky and probably bordering on harassment, if not being harassment outright. Rules are put in place for the protection of the patients; they’re not necessarily put in place to hinder a facilities right to collect on an outstanding debt, no matter how it feels to the employee. Sometimes it’s easy to send something out to the patient while staying under the radar of the rules. However, it will only cause problems for your facility at some point, especially if more than one person calls up to complain about the process.

Another problem is sending itemized statements out to the wrong people. It may be for the correct patient, and it may even be for someone in the same family, but unless someone has verified that this person has a right to the information, this will obviously be a violation of HIPAA privacy laws. Even today, billing personnel are sending itemized bills to the parent of a child of divorce who was brought into a facility by the other parent. Billing personnel needs to be educated that only the parent who brought a child into the facility is allowed to request an itemized bill. There are few computer systems that will list whether the child’s parents are divorced or not, so setting up this rule keeps your facility from not only being in the middle of a possible fight no one knew existed, but keeps you HIPAA compliant.

The same goes in the other direction, with an elderly patient whose children get into the fray. If someone has been granted power of attorney, usually there’s an indication given somewhere saying that’s the case, and only then should someone else be allowed to request a claim. There should also be some kind of department procedure put into place so a patient can allow someone else to speak on their behalf when it comes to questions about claims. I have interceded for my parents on a few occasions because I understand how the billing goes, and on those occasions I was glad I did because I discovered errors in the billing or cash posting process. Not saying that everyone would fully understand our process, but when it comes to claims, if your personnel are contacted by a third party representing the patient, there should be a consistent policy and process they can follow so they’re not inadvertently violating policy. Remember, it’s always possible the person on the other end of the line isn’t who they say they are.

I don’t want anyone to think I’m looking for managers to start micro-managing their departments. What I do want to get across is that if you have departments of any size, with varying degrees of responsibilities, it always helps if you know what processes some of your personnel are following in order to get their work completed. Sometimes, good performance may be a smoke screen for bad practices.