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Retired OIG Special Agent and Advize’s Director of Litigation & FWA Support will be stepping in each week to examine current fraud trends from the lens of an investigator. Stay tuned for weekly insights, updates, and information on healthcare’s most expensive crimes.

The past few days, I have spent time speaking to industry and government investigators, vendors and the like at the NAMPI conference.  During my chats, the one topic that continued to resonate throughout was the fact that providers continue to try to beat the system by seeking reimbursement for unbelievable numbers of hours of services, and my personal favorite, billing when out of the office.  Oftentimes, these cases are not investigated or resolved until the money has long since been paid, the provider has enjoyed the benefits of the fraud.

The prevailing question of why it takes so long to find the fraud in these situations, and why is it that the cases are not swiftly prosecuted, comes up as part of that discussion.  I think it is important to understand a few key points to be able to “see behind the curtain” to know what actually happens.  With respect to out of office billings, it is very difficult to know when a provider is not working (vacation, educational courses, etc.).  Of course, once it is alleged that a provider was out of the office, and may in fact have billed for services, it is “off to the races” so to speak.  Obtaining travel documents is the easiest way to identify blocks of time when a provider was away, and cross-referencing claims for reimbursement to those out of office dates makes for a good start to building a case.  Any good investigation will always include a variety of additional steps to corroborate the allegation.

The billing for high numbers of hours, however, can be a bit trickier.  A few instances of where it can be a lot of investigative work involves areas where “incident to” services are in question.  For those reading this, “incident to” can be a complex and difficult issue to explain to a prosecutor or to a jury.  In a nutshell, services that are rendered “incident to” a provider’s services can be covered when seeking reimbursement.  A great example is physical therapy.  Physical therapy complicates time related fraud investigations, because 15 minutes is not really 15 minutes (this can also be complicated with evaluation and management services, which are timed as well).

A 15-minute service can be as little as 8 minutes or as much as 22 minutes.  In effect, an investigator who obtains what is commonly known as an “impossible day scenario” report, may see an inordinate number of hours for physical therapy.  Additionally, because physical therapists can often time utilize the services of a physical therapy assistant (who do not bill separately), the number of hours of services identified by a specific NPI, may also be increased.  It can be a slippery slope to strictly interpret the number of hours into a fraud.

So, this may also be the case with providers who utilize non-physical practitioners in their practices (such as PA or NP level clinicians).  When working under the direct supervision of the billing provider (meaning, under “incident to” the provider is in the actual office suite—not to be confused with the false assumption that being available by telephone, email, carrier pigeon or the like will suffice), the services can be billed using the supervising provider’s NPI; making it appear that the billing provider is rendering many more services than are actually rendered.

Taking a close look at providers submitting for large numbers of hours in a particular day, the scrutiny needs to absolutely be there to identify potential mitigating factors.  Billing when a provider is out of the office, however, is a fraud area where I do not believe as much defensive “wiggle room” exists.  A few Facebook, Instagram or other social media photos, travel records, and some other investigative techniques, will work to create a solid investigation that negates any potential “wiggle room.”