Consultants' bad billing advice may elicit fraud investigation

Physicians need to be extra vigilant in making sure the people they rely on for advice aren't flouting the rules, experts tell a congressional panel.

By Tanya Albert, AMNews staff. July 23, 2001.

At a recent seminar teaching physicians about billing procedures, a consultant presented the group with a scenario: A relatively healthy 14-year-old boy comes into the office with a sore throat. How would you bill?

Not one of the physicians suggested they would bill as high as a "level four" visit. But the consultant told them it could be done.

Saying "documentation has its rewards," the consultant suggested that physicians document every aspect of the medical history and physical examination, and then count up the work documented to make all the services look more complicated than they actually were.

It sounds like an easy way to maximize profits. The only trouble with the advice: Doctors could find federal fraud investigators knocking on their doors if they follow it.

The real-life example was presented at a recent congressional hearing on health care consultants' advice. It was part of a General Accounting Office investigation that found that some consultants are recommending unethical and sometimes even illegal billing practices.

Sacramento, Calif., internist Kathryn Locatell, MD, who helped the GAO with its investigation, mentioned the incident as part of her testimony to the Senate Finance Committee. "On the face of it, it seems reasonable that higher reimbursement is given for more complicated physician work," she said. "However, what is missing from the schema is a defined way to determine that a given quantity of work was medically necessary."

At a time when federal investigators have gotten tough on health care fraud, they've now turned their attention to a consultant industry that offers physicians and others seminars that boil down the tens of thousands of pages of Medicare and Medicaid regulations and give suggestions on how to bill services. [...]