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Couple E/M question gray aeas to me. Advice please?!

My first question is in regard to the 95 and 97 guidelines and when Medicare -RAC does an audit.
Will they use the guidelines that suits THEM or will they always use the guidelines that benefits the physicians?

Also, if it’s an established patient and you need 2 out of 3…history and exam are perfect-comprehensive but MDM lacks complexity, can you still do a moderate using the history and exam, and not MDM?

And if I’m in a urology specialty but the patient has diabetes, CHF, COPD, basically things that the dr doesn’t necessarily treat, but might need to make medical decisions around that, can I bill those diagnoses? Or is it a matter of IF they put it in the assessment and plan? What if they put it there and list it. Can I count those as a point for established problem?
Do they actively have to be treating it on that encounter date? Where I’m struggeling is that they are not ‘treating’ the diabetes, etc. but it could be a factor in decision making.

Medical Billing and Coding Forum

Couple of case sceneros, are they fraud?

I have a couple case sceneros I’d like some opinions or thoughts on, if they would be considered fraudulent. It concerns a friend of mine, and I feel they are or at least unethical, but my friend was told they weren’t by another friends office manager she spoke to about it. She is fairly young and has only been working as a medical receptionist for a few years with this one office.

A supervisor has been over the practice for only a short period of time. (About 2-3 years) The past few months she has been working the aging reports, and having the office clerks sending out statements.Some/Most of the claims are well past timely filing limit. From 1 to 7 or 8 years or even older. Unless a patient calls in and says they have Medicaid 2nd, and state they can’t afford to pay. They are billed until they pay. If they do call in, the office clerks are to tell them they will need to come in with their card to show proof (alot of the patients live hours away) and only then will she provide a write off. If they do not do this, she says they are responsible for the balance and collects from them.

None have a ABN on file, in almost all cases the patients were not verbally notified or there is nothing noted in their accounts to show that they were, told the practice is a non-par. And again alot of the claims are aged by two years or more.

Also the office clerks are not to enter the Medicaid card (in inactive status)into the patient account to show reference for check in, check out or billing that the patient has medicaid secondary even just for informational purposes.

The 2nd scenero…
A clerk has a patient call in to pay her bill. This patient has Cigna coverage only, she has been paying religiously on a large surgical bill for the past few months. The office clerk finds when she pulls up the account it was showing a insurance credit balance of over $ 5,000. And a patient credit balance of $ 75.00. The clerk remembers this was an account that she herself had found the charges were actually billed out twice a couple of months ago and had already brought it to the supervisors attention, and at that time the supervisor told her to contact Cigna to recoup one of the payments, the clerk did… But clearly the patient had been continuing to recieve a statement and pay payments. Even though there is a credit balance in the system.

The clerk placed the patient on hold, and consulted with the supervisor, and was told "tell the patient the balance had been satisfied." Then continues to tell her that she "did not need to tell the patient she had a credit balance, nor that the surgery was billed out twice. Just that she did not owe anything else."

The patient understandably confused, asked for a print out of the fiancial history for her records. So the clerk, sent the patient a copy, and it shows the patient credit balance as well as the insurance credit, so the patient will see she is owed a refund.

But am I wrong thinking the supervisor is committing fraud or at the very least extremely shady? This is only 2 situations of several others, she has confided in me about. I’d just like to hear some thoughts on the best way to advise her.

Thanks for taking the time to read. I know it’s lengthy.

Medical Billing and Coding Forum