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Fees & Fraud-Too Close for Comfort

Compliance Basics
in Compliance Basics

Reimbursement Fraud Alert

Fees & Fraud-Too Close for Comfort

Walgreens Pharmacy has paid the penalty for a mix up in their billing and for ignoring federal rules when providing discounts. The article states, “Walgreens configured its systems so that pharmacists couldn’t dispense less than a full box of five insulin pens, and then it submitted false data in reimbursement claims indicating that the total number of daily doses didn’t go over program limits.” In other words, they provided a product but reported (billed) a different amount.

Could this happen to you?

Notice that the article says “submitted false data.” Yet a provider would say, “we submitted an incorrect claim.” Unfortunately, this mistake is not too far from reality for doctors of chiropractic. Walgreens created their software settings to dispense an item, similar to a DC setting up their software to report a certain service/procedure (using a particular procedure code). Yet, on the reimbursement claim Walgreens reported conflicting information. A DC could similarly provide a service yet when submitting the claim, present a different story than what was documented. A recurrent mistake when reporting units, diagnosis pointers, modifiers or procedure code could be considered ‘submitting false data.’ The second costly mistake was failing to disclose lower prices from their discount savings card to Medicaid prior to seeking reimbursement from Medicaid. Another big OOPS!

A simple mistake of miscommunication between two different workflow processes could cost you millions.

How can you avoid fraudulent billing? Ask yourself, when was the last time you took a look at your fee schedule? Do you provide discounts to your patients, if so, are they compliant? Does your billing team understand the importance of knowing when and how to implement discounts to federally funded beneficiaries? Do you audit your coding and billing on at least a quarterly basis? Can you say that your billing staff are truly trained to handle these responsibilities?

If you find yourself a bit hesitant when answering these questions, we encourage you to take the time to reach out to a KMC University Specialist for assistance with completing a coding audit in your clinic. If you feel your billing team could use some training, reach out to KMCU to find a course that can assist you. If you are library member, check out the great resources in the Office Management department.

Call (855) 832-6562 now or click to schedule a 15-minute Solution Consultation at your convenience.


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