• May


  • 1523

Good medical practice management includes proper billing and testing. These practitioners learned that the hard way. Two settlements demonstrate that the U.S. government has very little tolerance for providers who defraud its programs including Medicare, Medicaid and Federal Employee Health Benefits Program (FEHB).

Learn from these practice management mistakes.

Settlement 1: Garrett Okubo

Garrett Okubo is the owner and operator of a physical therapy business in Honolulu. According to the DOJ, Okubo submitted claims for physical therapy services between January 2011 and October 2017 for payment from Medicare, Medicaid, TRICARE, and the Hawaii Medical Service Association.

According to the DOJ, Okubo was in violation of 18 USC § 1347 for executing a scheme by “falsely stating that Okubo himself had personally provided the physical therapy services to patients, when in reality the services were provided by Okubo’s unlicensed staff members, including during times when Okubo was traveling on the U.S. mainland or in a foreign country.”

While Okubo is not a physician, the issues in this case are parallel to those of improper billing of non-physician providers (NPPs) such as physician assistants, nurse practitioners, and clinical nurse specialists. The result was a monetary penalty and jail time. It is important to reach state law to ascertain the scope of practice, licensure requirements and level of supervision to avoid penalties.

Settlement 2: Biotheranostics, Inc.

Biotheranostics, Inc. agreed to pay $2 million to resolve allegations that it submitted and caused the submission of Breast Cancer Index (BCI) tests for Medicare reimbursement. According to the DOJ, these tests were not “reasonable and necessary” therefore, failed to meet the medical necessity standard.

Medicare statutes state that laboratory tests may be reimbursed by Medicare only if they are “reasonable and necessary for the diagnosis or treatment of a patients’ illness or injury.” The DOJ determined through evidence-based medicine standards, that the BCI test was being performed on breast cancer patients who neither had been in remission for five years nor had been taking tamoxifen.

As a physician, the take-aways are:

  • NPPs are billing in the appropriate manner based on state and federal law and that the definition of “supervision” is applied.
  • The name on the claim’s submission form needs to the same as the one performing the service and indicated in medical records.
  • Diagnostic tests or treatments ordered must be substantiated by medical necessity.

Failing to be compliment could result in False Claims Act cases that can come with civil and criminal penalties. Get help with your medical practice management and medical billing. Contact us to learn more about Parasol Medical Billing and Coding solutions.