Managing Billing Mistakes Due to Lapsed Credentials: An Informational Guide for Physician Offices (Copy)
Keywords: billing mistakes, lapsed credentials, self-disclosure, CMS compliance, credentialing automation, physician offices, false claims, OIG self-disclosure, Medicare billing.
As a physician's office, ensuring that your staff's credentials are current and valid is critical, not only for the quality of care but also for maintaining compliance with billing requirements. This article explores the importance of proper credentialing, the potential pitfalls of billing errors due to lapsed credentials, the intricacies of self-disclosure, and how automation can be a game-changer in this area.
The Role of Credentials in Billing
Credentialing verifies that healthcare providers meet the necessary qualifications and standards to practice in their field. This process includes licensure, certifications, training, and other professional qualifications. In a physician's office, key credentials include medical licenses, board certifications, DEA registrations, and NPI (National Provider Identifier) numbers. These credentials are essential for accurately billing services to federal healthcare programs like Medicare and Medicaid.
Why Credentials Matter for Billing Federal Beneficiaries
Federal healthcare programs require that only properly credentialed providers deliver services for which reimbursement is sought. This is a safeguard to ensure that patients receive care from qualified professionals. Billing for services rendered by a provider with lapsed or expired credentials can be considered fraudulent, even if the lapse was unintentional. As a result, offices must be vigilant in maintaining up-to-date credentials for every provider involved in patient care.
Billing Mistakes Due to Lapsed Credentials
A common billing error arises when services are billed under a provider whose credentials have expired or lapsed. This mistake can lead to:
Denial of Claims: If Medicare or Medicaid discovers a credentialing issue during the claim processing stage, the claim may be denied, resulting in delays in payment.
Overpayment Recoveries: If services were paid for before a lapse was discovered, the physician's office may need to repay the amount to the contractor.
False Claims Act Violations: Submitting claims for services provided by uncredentialed staff may trigger liability under the False Claims Act, leading to significant penalties.
CMS Operating Manuals and Credentialing Compliance
The Centers for Medicare & Medicaid Services (CMS) has specific guidelines regarding credentialing in its operating manuals. Manuals such as the Medicare Program Integrity Manual and the Medicare Benefit Policy Manual stress the need for proper documentation of provider credentials. They require that services billed to Medicare are provided by licensed and credentialed providers to ensure compliance with federal regulations. Physician offices must regularly review these manuals to remain compliant.
Managing False Claims Due to Credentialing Issues
When a billing mistake arises due to a credentialing issue, physician offices face a crucial decision: whether to self-disclose the error or simply return the overpaid amount to the contractor. Key considerations include:
Returning Overpayments: Returning overpaid funds to a Medicare contractor is necessary within 60 days of identifying the overpayment, per the Affordable Care Act. However, this step alone may not absolve the office of liability if the mistake constitutes a violation of federal regulations.
Self-Disclosure Protocol: Center for Medicare & Medicaid Services (CMS) and the Office of Inspector General (OIG) provide protocols for self-disclosing overpayments or violations. This may be necessary when a billing error involves potential violations of federal law, like the False Claims Act (FSA).
Risks of Just Returning the Money
Simply returning an overpayment can leave a physician's office vulnerable if the issue qualifies as a violation under federal law. The OIG or the Department of Justice (DOJ) may later determine that the office failed to report a known violation. This could result in:
Liability Under the False Claims Act: Failure to fully disclose known violations could lead to accusations of concealing fraud.
Potential Penalties: The office may face additional financial penalties if regulators deem that the repayment did not satisfy the obligation to report a violation.
Pros and Cons of Self-Disclosure
Pros:
Reduced Penalties: Self-disclosing to the OIG can potentially reduce penalties compared to what might be imposed if the issue is discovered during an audit.
Demonstrates Compliance Efforts: Voluntary disclosure shows good faith and a commitment to compliance, which may be favorable in the eyes of regulators.
Avoiding Legal Escalation: Self-disclosure can sometimes prevent the escalation of an issue to a formal investigation by the DOJ.
Cons:
Admission of Liability: Self-disclosure may be interpreted as admitting to a violation, which could be used against the office in future investigations or lawsuits.
Potential for Oversight: Self-disclosure can trigger a broader review of the physician's office's billing practices, leading to increased scrutiny.
Financial Costs: Even with a reduction in penalties, the office may still face fines, repayment of overpayments, and the costs of implementing corrective actions.
Determining Whether Self-Disclosure is Necessary
To determine whether a billing mistake requires self-disclosure or if returning the funds is sufficient, physician offices should:
Consult Legal Counsel: Legal experts can assess the nature of the billing error and guide the decision-making process.
Review CMS and OIG Guidelines: Understanding the specific requirements for reporting overpayments or violations is critical for compliance.
Evaluate the Scope of the Issue: The more systemic and widespread the issue, the more likely self-disclosure may be required.
Possible Results of Self-Disclosure
Physician offices should be prepared for potential outcomes of self-disclosure, including:
Fees and Penalties: Even with a reduced penalty, financial repercussions can still be significant.
Investigations and Compliance Reviews: CMS or OIG may conduct a more thorough investigation into the office's practices.
Exclusion from Federal Programs: In severe cases, providers may face temporary or permanent exclusion from Medicare and Medicaid.
Loss of Licensure: Repeated violations can result in professional disciplinary actions, including the loss of medical licenses.
How Automation Can Help Avert Credentialing Issues
Automating credentialing processes can significantly reduce the risk of billing mistakes related to lapsed credentials. Credentialing software can:
Track Expiration Dates: Automated systems can monitor licenses, certifications, and DEA registrations, sending reminders when renewals are due.
Centralize Documentation: Digital platforms allow for easy access to up-to-date credentialing information, reducing administrative errors.
Ensure Compliance: Automated systems can ensure that only properly credentialed providers are associated with claims, preventing improper billing before it occurs.
Conclusion
Maintaining up-to-date credentials is not just an administrative task—it's a compliance necessity for physician offices billing federal programs. Understanding when to self-disclose and how to navigate credentialing issues can save a practice from significant financial and legal consequences. With the right tools, like automated credentialing software, practices can streamline these processes, ensuring compliance and focusing on patient care without the fear of unintended billing mistakes.
Disclaimer: This article is for educational and informational purposes only. It is not intended as legal advice. Each self-disclosure case is unique, and nursing homes should consult with qualified legal counsel to address the specific complexities and risks involved in their situation. Engaging legal professionals ensures that appropriate steps are taken and that compliance with all relevant laws and regulations is maintained.
