OIG deputizes billers as fraud police

Under the new compliance model for third-party billers issued by the Office of the Inspector General (OIG) last December, billing companies are directed not to submit for payment any claims they feel are dubious. Instead, they are instructed to notify the provider of their concerns in writing within 30 days.

If the provider "flagrantly" continues to submit questionable claims, the guidance suggests the billing company resign the contract and report any reliable suspicions to the OIG.

Included in the guidance are 17 specific kinds of abuses billers are instructed to watch for:

• billing for undocumented services or items;

• duplicate billing;

• upcoding;

• unbundling;

• improper use of modifiers;

• inappropriate balance billing;

• poor or no resolution of overpayments;

• lack of computer system integrity;

• computer systems with fields requiring information to be entered indicating services were rendered when they either were not properly rendered or were not completely documented;

• unsecured records/information;

• willful misuse of provider ID number;

• outpatient services rendered in connection with inpatient stays;

• improperly billing a transfer as a discharge;

• incentives from clients to violate anti-kickback or other compliance regulations;

• joint ventures;

• improper discounts on professional services;

• improper waiver of copayments.