A November 25 article in Part B News, “Third-party biller fraud may hook your practice, unless you protect yourself,” discussed the federal government’s recent fraud investigation of a medical biller in New York State and healthcare providers’ obligation to ensure the accuracy of their claims billing. Rivkin Radler’s Jeff Kaiser was quoted in the article.
The article points out that percentage-based compensation arrangements between a practice and a billing company are unlawful in the State of New York and can be problematic elsewhere as well, but Jeff said that charging a practice a flat monthly fee could also allow the biller to misbehave. “If a biller charges a percentage of collections… there would be an obvious financial motive for the biller to upcode the claims and increase the reimbursement amounts,” Jeff observed. However, “if the biller is receiving a fixed monthly fee… it is still possible that the biller could falsify claims submissions and then — particularly if the biller was also performing management and administrative services, as in the cited case — keep the ‘delta’ between the inflated reimbursement amounts and the true reimbursement amounts, returning only the lower amount to the provider.”
And now, some cautionary words: Rivkin Radler’s healthcare attorneys are aware, anecdotally, that some healthcare providers continue to maintain percentage-based billing arrangements even where it is prohibited. If your practice is doing this and you haven’t checked it with healthcare counsel, please speak to them. Also, just to confirm, a provider is responsible for the accuracy of its own claims, even when the bills are prepared and submitted by a third-party biller.
