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While employee theft brings a picture of people walking out with petty cash or supplies, your program’s financial assets can be put at risk by the people responsible for coding, filing claims, and collecting payments, says Dawn Q. McLane, RN, MSA, CNOR, executive director of Allied Physicians Surgery Center in South Bend, IN.
Miscoding or upcoding claims can open your program to charges of insurance fraud, even if the inaccurate coding is inadvertent. Making sure you educate employees and physicians as to the need for accurate coding and documentation is an essential first step to protecting your participation in Medicare and managed care programs, McLane points out. (For more information on accurate outpatient surgery coding, see Same-Day Surgery, March 2001.)
Establish procedures that ensure accurate coding, and tell insurers how you ensure accurate coding, she adds. Removal of lesions is a good example, McLane says. "Lesions under 3.1 cm are not approved for removal in a same-day surgery center if Medicare is the payer, but lesions can shrink in formalin," she explains. For this reason, surgeons in McLane’s center perform a field measurement of the lesion after removal while the lesion is still on the sterile field. The surgeons dictate this information in their operative notes, says McLane. "This gives us a true measurement and good documentation," she says. It also protects her facility by ensuring proper reimbursement, she adds.
Another insurance-related fraud might occur in small facilities or physician offices when a claim for a complicated procedure is submitted, says Robert W. Scheller, CPA, vice president of operations for Aspen Healthcare, a surgical center development and management firm in Boulder, CO. "The more complex procedure is reimbursed, but the billing office records are made to show a simple procedure, and the difference in reimbursement is pocketed by the employee," he explains. Managers can avoid this fraud with segregation of duties and comparison of procedure logs with description of claims filed, he adds.
A common embezzlement scheme seen in health care facilities is referred to as "lapping," says Ronald Ralph, CPA, a partner in the health care services group of Crowe, Chizek, and Co., a South Bend, IN-based accounting firm that does business, public sector, and information technology consulting. "An employee will pocket a payment from one patient, then use payments from other patients to cover the balance," he explains.
This type of fraud may take a while to discover because a patient won’t complain unless they are getting invoices and past-due notices, he explains. This fraud occurs with cash payments made by the patient as well as insurance payments, he adds. Discourage this type of fraud by making sure that more than one employee is involved in the collection, posting, and depositing of funds, Ralph says.