Local Physician and Practice Agree to Pay Over $2 Million to Settle False Claims Act Allegations

Press Release from U.S. Attorney’s Office, Eastern District of Michigan:

I don’t normally report on False Claims Act (FCA) matters from other states, but this one serves as a cautionary tale on “incident to” billing.

Under Medicare rules, covered services provided by non-physician practitioners (NPPs), like physician assistants, nurse practitioners, clinical nurse specialists, etc., are reimbursed at a reduced rate of 85 percent of the fee schedule amount.

The “incident-to” billing rules provide an exception, allowing 100 percent reimbursement for NPP services that meet the requirements detailed in the Medicare Benefit Policy Manual, Chapter 15, Section 60 (Services and Supplies Furnished Incident To a Physician’s/NPP’s Professional Service).

Among other requirements, to bill a NPPs services as “incident to” the physician’s initial evaluation, the physician must provide direct supervision. Without direct supervision, the NPPs services must be billed under the NPPs provider number at the reduced rate.

Direct supervision in the office setting does not mean that the physician must be present in the same room, but the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the aide is performing services.

Direct supervision in the home health setting, requires the physician to be physically present in the home to oversee the care.

In this reported FCA settlement, the NPP’s home health services were being billed “incident to” the physician’s services, but the physician was not physicially present in the home. Thus, the physican and his practice falsely claimed an extra 15% reimbursement on all those services.

The physician and his practice paid $2,003,800.91 to resolve the FCA allegations.

The moral of the story … know the rules about billing, and if you don’t, hire someone who does.