Guest Column | November 2, 2018

How On-Demand Care Clinics Can Avoid False Claims Penalties And Stay Compliant

By Monte Sandler, DocuTAP

Regulatory Compliance Elevated Standards

It’s clear that urgent care clinics are becoming a top choice for many patients seeking on-demand medical care and as an alternative to the emergency room. If it’s any indication, a recent FAIR Health Report suggests that from 2007 to 2016 urgent care centers showed an increase in claim lines of 1,725 percent – far surpassing the growth in emergency room claim lines during that same period. What this means for urgent cares is more patients, and as a result, more claims.

Processing an increasing number of claims can be a challenge for clinics without a billing service, not only because of the volume, but also because private payers have different policies and guidelines that can be confusing and difficult to keep up with. While many payers follow CMS (Centers for Medicare and Medicaid Services) guidelines, regulations can still vary by both state and payer.

The biggest challenges to maintaining compliant billing for urgent cares are ensuring all providers are properly credentialed and that claims involving non-physician care providers are handled and coded properly according to the Federal False Claim Act (FCA). In order to maintain compliance, it’s important to first understand what constitutes a false claim.

According to the False Claim Act, it is a crime for any person or organization to:

  • Knowingly present, or causing to be presented, a false or fraudulent claim for payment or approval;
  • knowingly make, use, or cause to be made or used, a false record or statement material to a false or fraudulent claim;
  • conspire to commit a violation of the Federal False Claims Act; and
  • knowingly make, use, or cause to be made or used, a false record or statement material to an obligation to pay or transmit money or property to the Government, or knowingly conceal or knowingly and improperly avoid or decrease an obligation to pay or transmit money or property to the government.

At the same time, States also have additional rules and regulations that may apply. While incorrect or fraudulent billing may not be the intent of a provider or clinic, without careful oversight and expert billers, the risk of non-compliance – and the cost of litigation – is high.

In February of 2017, the FCA raised the monetary penalties for submitting false claims from a minimum of $10,957 to a maximum of $21,916 per claim. According to a recent report released by the Office of the Inspector General (OIG), Medicaid fraud control units (MFCUs) recovered $1.8 billion in 2017 in cases involving fraud and patient abuse.

Some examples of false claims are billing for services not provided, billing for the same service more than once, making false statements to obtain payment for services and improper use of a National Provider Identifier (NPI) by mid-level and other providers. To facilitate quicker reimbursement, it can be tempting for urgent care groups to submit claims under a credentialed physicians name while the rendering physician has not been credentialed by a specific private payer. This constitutes a false claim under the law, so it is prudent (and legal) to hold claims until credentialing is complete.

Now that we know what constitutes a false claim, let’s dive into the steps urgent cares can take to make sure risk is lowered and compliance is achieved.

  1. Make compliance and credentialing top priorities

While the main purpose of a medical practice is medicine and patient care, a good amount of emphasis must be placed on credentialing, proper billing and accurate coding. With changing contracts and controls by payers, it’s essential to designate one or more people to be responsible for keeping billing on track based on the size of the practice. These clinic experts should understand the correct use of NPIs for practitioners and caregivers at every level – don’t wait until you get fined before paying attention.

  1. Understand federal guidelines

According to federal guidelines for Medicare and Medicaid, every provider must be individually credentialed with all services billed under the rendering provider. Be sure that everyone who touches a claim or billing documentation understands these and all regulations around compliance that could result in false claims.

CMS and most payers also provide for Incident-to billing for some claims. This is a method of billing for incidental services performed by non-physician practitioners and non-physician employees in accordance with the physician’s treatment plan. This situation is uncommon in the urgent care setting. For a service to be incidental, it must be a part of a physician’s treatment plan. This eliminates new patients, patients with new conditions, or patients with a worsening condition. In urgent care, nearly all patients are new and follow up is done with a primary care physician.

There are generally two instances in which a physician can legally bill under the NPI of another physician with the appropriate modifier: reciprocal billing arrangements and fee-for-time compensation arrangements.

  1. Read every contract

Outside of Medicare and Medicaid claims, the process can get more confusing. Private payers are not required by law to meet the same CMS guidelines, but contractual billing requirements may vary based on state guidelines and other factors.

There is risk in not following contractual requirements – the payer may recoup what they reimbursed you, or you could lose the contract altogether. Be sure you have an experienced professional go through all payer contracts so everyone on your billing team understands any subtle differences that apply.

  1. Educate your billing team.

Simply put, your billing team is your revenue lifeline. Each person that is involved in the billing and claims processes must know federal requirements and the requirements of each payer. To mitigate risk of false claims, they must have a thorough understanding of regulations, pay attention to details and insist on accuracy for every claim.

In today's healthcare environment, it’s more important than ever that clinics follow appropriate billing guidelines for each contract with third-party payers and make compliance a top priority. If these steps are followed, urgent care clinics can lower non-compliance risk. In addition, one of the biggest benefits to submitting clean, compliant claims is that urgent cares will optimize reimbursements for all the work done making the practice more profitable. What’s more, the heightened attention to detail of accurate billing means patient satisfaction will continue to be high. Overall, it’s a clear win-win situation – compliance keeps everyone happy.

About The AuthorMonte Sandler, DocuTAP

Monte Sandler is Executive Vice President of Revenue Cycle Management for DocuTAP.