Have I just witnessed healthcare fraud?

[Marasmus1]

For the folks who are experienced in billing, my wife recently switched her mental healthcare services to a new agency due to my relocation and started seeing an NP owned practice (yes it is sad but current location average length of wait for psychiatrist is 3 months) . So far she received 6 sessions which pretty much consisted of a phone call from an NP for 5 minutes to refill her medication. It was recently brought into my attention after I received outstanding bills from this practice as we still have deductibles based on our insurance policy. So basically they charged us with Office Outpatient visit EST + PSYTX PT&/FAM W/E&M 60 MIN for 5 minutes phone calls with total reimbursement of 325$ for each follow up from our insurance (which is applied to our deductible).

After calling them for the last two weeks every single day and not being able to reach out anybody to speak to in their billing department, I shot them an email and finally somebody got back to me. I disputed the psychotherapy add on and the reply I got was our state allowed them to bill this way independent of the time prescriber spent with my wife. At this point, I disclosed them that I am a psychiatrist and although I do not know the specifics of this state`s rules yet, I will talk to my hospitals billing department and legal department before I respond them. At this point the person on the other side took my name and they waived the psychotherapy add on charges. Now;

1) Is this healthcare fraud?
2) If it is , then what are the agencies I should be reporting them to ?

It seems the NP practices independently as my current state allows them to do so. As I digged deep, said NP listed psychodynamic psychotherapy, cognitive behavioral therapy, dialectical behavioral therapy, EMDR, mentalization based therapy, acceptance and commitment therapy, motivational interviewing, spiritual counseling and family therapy among their expertise in psychology today

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[calvinhobbes]

Yes, it is fraud. Yes, I would report them and quickly to the dept of consumer affairs, health dept, board of medicine, board of nursing, etc. And you as a physician and psychiatrist have an in-depth understanding of when something is wrong. You did the right thing calling them out — now report them so they don’t do it to someone else with less means or education. Ugh, NPs are awful.

 

[SubzDoc]

If it turns out that they are correct and your state allows billing fraud can you please DM me which state so I can move there?

 

[calvnandhobbs68]

For the folks who are experienced in billing, my wife recently switched her mental healthcare services to a new agency due to my relocation and started seeing an NP owned practice (yes it is sad but current location average length of wait for psychiatrist is 3 months) . So far she received 6 sessions which pretty much consisted of a phone call from an NP for 5 minutes to refill her medication. It was recently brought into my attention after I received outstanding bills from this practice as we still have deductibles based on our insurance policy. So basically they charged us with Office Outpatient visit EST + PSYTX PT&/FAM W/E&M 60 MIN for 5 minutes phone calls with total reimbursement of 325$ for each follow up from our insurance (which is applied to our deductible).

After calling them for the last two weeks every single day and not being able to reach out anybody to speak to in their billing department, I shot them an email and finally somebody got back to me. I disputed the psychotherapy add on and the reply I got was our state allowed them to bill this way independent of the time prescriber spent with my wife. At this point, I disclosed them that I am a psychiatrist and although I do not know the specifics of this state`s rules yet, I will talk to my hospitals billing department and legal department before I respond them. At this point the person on the other side took my name and they waived the psychotherapy add on charges. Now;

1) Is this healthcare fraud?
2) If it is , then what are the agencies I should be reporting them to ?

It seems the NP practices independently as my current state allows them to do so. As I digged deep, said NP listed psychodynamic psychotherapy, cognitive behavioral therapy, dialectical behavioral therapy, EMDR, mentalization based therapy, acceptance and commitment therapy, motivational interviewing, spiritual counseling and family therapy among their expertise in psychology today

So, I wouldn't start with reporting them to any agencies. I would start with your insurance company. They are at the heart of it obviously billing for services they did not provide, which would fall under fraudulently charging insurance, even if you're ultimately paying because you haven't met your deductible yet (because it's being applied towards your deductible). Call the member line for your insurance company and tell them you want to report fraudulent billing for a provider submitting charges for services they did not provide....even if they're telling you they're "waiving" the fees for now they still submitted the charges to the insurance company. If this goes anywhere, it may trigger an audit by the insurance company of this practice's records.

I would also make sure you record the start and stop times (take screenshots of the phone calls if it's just a phone call and not a telemedicine platform) and dates of any telemedicine appointments she has with them, so you clearly have a recorded trail of evidence which will show there is no way she spent enough time to do a psychotherapy add on code. It's not like she's even spending 20 minutes and trying to bill a 90833...she's billing a freaking 90838 which I'd expect to be triggering audits anyway but whatever.

You could also report her to the board of nursing in your state but that depends if you want to stay patients there or not...

If it's private insurance, you can't report them to CMS as far as I know because this is a private contract between the insurer and the practice, what this is is insurance fraud (same way if you claimed fire damage or said your car was stolen but it didn't actually happen...she's submitting a claim for a service she didn't provide).

 

[nexus73]

Nps have no training in psychotherapy that I’ve seen. At best 1 patient for 3 months with supervision. But more likely therapy training was sitting in groups on an inpatient unit observing only and having that signed off as therapy training.

 

[PikminOC]

So, I wouldn't start with reporting them to any agencies. I would start with your insurance company. They are at the heart of it obviously billing for services they did not provide, which would fall under fraudulently charging insurance, even if you're ultimately paying because you haven't met your deductible yet (because it's being applied towards your deductible). Call the member line for your insurance company and tell them you want to report fraudulent billing for a provider submitting charges for services they did not provide....even if they're telling you they're "waiving" the fees for now they still submitted the charges to the insurance company. If this goes anywhere, it may trigger an audit by the insurance company of this practice's records.

I would also make sure you record the start and stop times (take screenshots of the phone calls if it's just a phone call and not a telemedicine platform) and dates of any telemedicine appointments she has with them, so you clearly have a recorded trail of evidence which will show there is no way she spent enough time to do a psychotherapy add on code. It's not like she's even spending 20 minutes and trying to bill a 90833...she's billing a freaking 90838 which I'd expect to be triggering audits anyway but whatever.

You could also report her to the board of nursing in your state but that depends if you want to stay patients there or not...

If it's private insurance, you can't report them to CMS as far as I know because this is a private contract between the insurer and the practice, what this is is insurance fraud (same way if you claimed fire damage or said your car was stolen but it didn't actually happen...she's submitting a claim for a service she didn't provide).

Calvin is correct.

 

[wholeheartedly]

So, I wouldn't start with reporting them to any agencies. I would start with your insurance company. They are at the heart of it obviously billing for services they did not provide, which would fall under fraudulently charging insurance, even if you're ultimately paying because you haven't met your deductible yet (because it's being applied towards your deductible). Call the member line for your insurance company and tell them you want to report fraudulent billing for a provider submitting charges for services they did not provide....even if they're telling you they're "waiving" the fees for now they still submitted the charges to the insurance company. If this goes anywhere, it may trigger an audit by the insurance company of this practice's records.

I would also make sure you record the start and stop times (take screenshots of the phone calls if it's just a phone call and not a telemedicine platform) and dates of any telemedicine appointments she has with them, so you clearly have a recorded trail of evidence which will show there is no way she spent enough time to do a psychotherapy add on code. It's not like she's even spending 20 minutes and trying to bill a 90833...she's billing a freaking 90838 which I'd expect to be triggering audits anyway but whatever.

You could also report her to the board of nursing in your state but that depends if you want to stay patients there or not...

If it's private insurance, you can't report them to CMS as far as I know because this is a private contract between the insurer and the practice, what this is is insurance fraud (same way if you claimed fire damage or said your car was stolen but it didn't actually happen...she's submitting a claim for a service she didn't provide).

While it might be private insurance for the OP, would there still be a benefit reporting to CMS because they are likely doing this to a lot of patients, including some probably under CMS jurisdiction?

 

[calvnandhobbs68]

While it might be private insurance for the OP, would there still be a benefit reporting to CMS because they are likely doing this to a lot of patients, including some probably under CMS jurisdiction?

Well that would assume that they even take Medicare anyway. I’m not even sure there’s a mechanism for doing this if you’re not a Medicare beneficiary though or have evidence of Medicare fraud. I don’t think it’d actually go anywhere but I guess OP could try? The way he stops getting them to stop doing this to him though is through his insurance company.

 

[PikminOC]

For the folks who are experienced in billing, my wife recently switched her mental healthcare services to a new agency due to my relocation and started seeing an NP owned practice (yes it is sad but current location average length of wait for psychiatrist is 3 months) . So far she received 6 sessions which pretty much consisted of a phone call from an NP for 5 minutes to refill her medication. It was recently brought into my attention after I received outstanding bills from this practice as we still have deductibles based on our insurance policy. So basically they charged us with Office Outpatient visit EST + PSYTX PT&/FAM W/E&M 60 MIN for 5 minutes phone calls with total reimbursement of 325$ for each follow up from our insurance (which is applied to our deductible).

After calling them for the last two weeks every single day and not being able to reach out anybody to speak to in their billing department, I shot them an email and finally somebody got back to me. I disputed the psychotherapy add on and the reply I got was our state allowed them to bill this way independent of the time prescriber spent with my wife. At this point, I disclosed them that I am a psychiatrist and although I do not know the specifics of this state`s rules yet, I will talk to my hospitals billing department and legal department before I respond them. At this point the person on the other side took my name and they waived the psychotherapy add on charges. Now;

1) Is this healthcare fraud?
2) If it is , then what are the agencies I should be reporting them to ?

It seems the NP practices independently as my current state allows them to do so. As I digged deep, said NP listed psychodynamic psychotherapy, cognitive behavioral therapy, dialectical behavioral therapy, EMDR, mentalization based therapy, acceptance and commitment therapy, motivational interviewing, spiritual counseling and family therapy among their expertise in psychology today

Is the np in network or out of network with your insurance?

 

[smalltownpsych]

For the folks who are experienced in billing, my wife recently switched her mental healthcare services to a new agency due to my relocation and started seeing an NP owned practice (yes it is sad but current location average length of wait for psychiatrist is 3 months) . So far she received 6 sessions which pretty much consisted of a phone call from an NP for 5 minutes to refill her medication. It was recently brought into my attention after I received outstanding bills from this practice as we still have deductibles based on our insurance policy. So basically they charged us with Office Outpatient visit EST + PSYTX PT&/FAM W/E&M 60 MIN for 5 minutes phone calls with total reimbursement of 325$ for each follow up from our insurance (which is applied to our deductible).

After calling them for the last two weeks every single day and not being able to reach out anybody to speak to in their billing department, I shot them an email and finally somebody got back to me. I disputed the psychotherapy add on and the reply I got was our state allowed them to bill this way independent of the time prescriber spent with my wife. At this point, I disclosed them that I am a psychiatrist and although I do not know the specifics of this state`s rules yet, I will talk to my hospitals billing department and legal department before I respond them. At this point the person on the other side took my name and they waived the psychotherapy add on charges. Now;

1) Is this healthcare fraud?
2) If it is , then what are the agencies I should be reporting them to ?

It seems the NP practices independently as my current state allows them to do so. As I digged deep, said NP listed psychodynamic psychotherapy, cognitive behavioral therapy, dialectical behavioral therapy, EMDR, mentalization based therapy, acceptance and commitment therapy, motivational interviewing, spiritual counseling and family therapy among their expertise in psychology today

Billing insurance for a service when you did not provide it would be insurance fraud. No way can they justify providing any psychotherapy in a five minute phone call. I think that this is actually a criminal offense in most jurisdictions. If this is an agency, then maybe some local law enforcement or press agencies would want to get involved. Independent medical practice plus stupidity is not a good combination. At least with the local counselors in the community, they can’t really generate enough revenue or business typically to be that dangerous, mainly just annoying, but whole different story when you can bill insurance for that much in one visit and have ADHD clients by the boatload.

 

[splik]

Yes this is fraudulent and states do not have any role in regulations around billing so that is just ridiculous. Licensing boards do not usually get involved in billing issues so there is no point in complaining to the NP board. However you can certainly complain to the insurance company as they can investigate and mete out consequences including clawbacks, penalties and kicking them off the panel. If they do take Medicare then under the qui tam provision if you report to OIG as a whistleblower you’re entitled to a cut of the money the government collects. Only worth it if they are a bigger operation and doing this on a large scale. That can lead to criminal penalties as well.

 

[deleted1100659]

The funny thing is that it is very easy to subpoena phone call records. Extremely easy to prove the exact duration of a phone visit, while an in person visit its not always easy to verify the time spent.

 

[clausewitz2]

I know socially a prosecutor in my state who heads up a unit whose entire purpose is prosecuting health insurance fraud. One report isn't going to trigger a really thorough investigation on its own but a pattern of reports about this sort of thing might. Regardless, your state attorney general's office might be interested in your experience.

 

[MedMan80]

5 min x 20 x $325 = 6500 bucks an hour

 

[allantois]

5 min x 20 x $325 = 6500 bucks an hour

I doubt they are seeing that many in an hour

 

[nexus73]

I doubt they are seeing that many in an hour

You doubt the efficiency of a heart of a nurse?

 

[allantois]

You doubt the efficiency of a heart of a nurse?

Nurses are not efficient..

I wouldn't be surprised if she takes 55 mins to chart..

 

[ObsequiousAplomb]

5 min x 20 x $325 = 6500 bucks an hour

I don't understand your math here? 5 minutes each with 0 minutes charting is 12 encounters per hour, not 20. 20 encounters is 3 minutes each.

12 x $325 = $4000 per hour.

More realistically, it would be at least 1-2 minutes between the encounters to switch to the next phone call / finalize charting that wasn't done during the call. So more like 9.25 per hour.

9.25 x $325 = $3000 per hour.

 

[TexasPhysician]

With private insurance, you could argue fraud to an agency, but the state/government likely doesn’t care. You need Medicare/Medicaid involvement for that. This is fraud between a private company and the NP. If the NP is regularly billing that a few times per hour, it’ll trigger an audit even if you do nothing. You can’t argue 38+ minutes of therapy multiple times per hour thinking you won’t get caught. Go ahead and report to insurance what is happening though.

I’m not an insurance expert, but I recall certain agencies/insurances allowing phone only visits to count as typical E&M due to the National emergency. We can’t expect everyone to have high speed internet, cameras, and speakers readily available. Caring for 80+ year old patients when they aren’t around family and are told to isolate at home to avoid Covid is next to impossible to do perfectly with video. This all may have ended or will likely end with the National emergency ending. This makes half of your statements accurate now if I’m correct. It would only be the therapy component that is inaccurate.

 

[calvnandhobbs68]

With private insurance, you could argue fraud to an agency, but the state/government likely doesn’t care. You need Medicare/Medicaid involvement for that. This is fraud between a private company and the NP. If the NP is regularly billing that a few times per hour, it’ll trigger an audit even if you do nothing. You can’t argue 38+ minutes of therapy multiple times per hour thinking you won’t get caught. Go ahead and report to insurance what is happening though.

I’m not an insurance expert, but I recall certain agencies/insurances allowing phone only visits to count as typical E&M due to the National emergency. We can’t expect everyone to have high speed internet, cameras, and speakers readily available. Caring for 80+ year old patients when they aren’t around family and are told to isolate at home to avoid Covid is next to impossible to do perfectly with video. This all may have ended or will likely end with the National emergency ending. This makes half of your statements accurate now if I’m correct. It would only be the therapy component that is inaccurate.

Yes but you could imagine they could be completely falsifying records as well in a way that’ll pass a normal audit. For instance, actually just scheduling one patient an hour, doing their 5 minute phone call, billing a E+M and psychotherapy add on, documenting as if they did this and then reading the news for the rest of the hour. Audits also don’t see how many patients you’re scheduling per hour, just documentation, so say you have a patient with BCBS scheduled from 10-10:30 and then a patient with United scheduled from 10:30-11, they can’t pull each other’s charts to see that you documented both as 10-11. So there can be all kinds of shady stuff going on here.

I suspect consistently billing like this will trigger an audit at some point too but without the patient complaint, they won’t have the info of how long the appointment actually lasted

 

[randomdoc1]

This is more common than many of us imagine probably.

 

[ObsequiousAplomb]

With private insurance, you could argue fraud to an agency, but the state/government likely doesn’t care. You need Medicare/Medicaid involvement for that. This is fraud between a private company and the NP. If the NP is regularly billing that a few times per hour, it’ll trigger an audit even if you do nothing. You can’t argue 38+ minutes of therapy multiple times per hour thinking you won’t get caught. Go ahead and report to insurance what is happening though.

I’m not an insurance expert, but I recall certain agencies/insurances allowing phone only visits to count as typical E&M due to the National emergency. We can’t expect everyone to have high speed internet, cameras, and speakers readily available. Caring for 80+ year old patients when they aren’t around family and are told to isolate at home to avoid Covid is next to impossible to do perfectly with video. This all may have ended or will likely end with the National emergency ending. This makes half of your statements accurate now if I’m correct. It would only be the therapy component that is inaccurate.

The OP says the bill is for the 60 minute psychotherapy add-on, which would be a minimum of 55 minutes psychotherapy. It could be reasonable to spend only 5 minutes face-to-face for an E&M refill on a stable patient, provided the other stuff is done non-face-to-face (but I certainly don't do that).

 

[TexasPhysician]

Yes but you could imagine they could be completely falsifying records as well in a way that’ll pass a normal audit. For instance, actually just scheduling one patient an hour, doing their 5 minute phone call, billing a E+M and psychotherapy add on, documenting as if they did this and then reading the news for the rest of the hour. Audits also don’t see how many patients you’re scheduling per hour, just documentation, so say you have a patient with BCBS scheduled from 10-10:30 and then a patient with United scheduled from 10:30-11, they can’t pull each other’s charts to see that you documented both as 10-11. So there can be all kinds of shady stuff going on here.

I suspect consistently billing like this will trigger an audit at some point too but without the patient complaint, they won’t have the info of how long the appointment actually lasted

With evidence, you could likely make a nursing board complaint, but I’ve been really discouraged by the results of my board complaints in the past.

Even the Federal government is very chill on issues unless it is outrageous. Blatant ongoing HIPAA violations are warnings fyi. Really need excessive Medicare 99214 + psychotherapy multiple times per hour for them to care sadly.

 

[Merovinge]

Wow, I sit here wondering if I spend 39 minutes with a patient/charting and then quickly browse SDN for 1 minute if I can justify a 99215 based on time. It appears I've completely missed the scope of real fraud with billing and how some outpatient practices can be so lucrative with insurance.

 

[smalltownpsych]

Wow, I sit here wondering if I spend 39 minutes with a patient/charting and then quickly browse SDN for 1 minute if I can justify a 99215 based on time. It appears I've completely missed the scope of real fraud with billing and how some outpatient practices can be so lucrative with insurance.

I think the example points to being able to spend a minute with patient and the rest of the time on SDN. Of course, then you are only making nurse wages. A fraudulent doctor would bill for complex E/M and a therapy add on every ten minutes or if you really want to work as hard as another poster stated 5 minutes per patient 20 times an hour. 🤪
In my mind this is so clearly fraudulent, this should be criminal. Meanwhile I would worry about whether I could bill for the times I would go to the hospital and client was too psychotic to do any therapy with but I still had to evaluate and make decisions and recommendations and 90832 was really the only code I had.

 

[Mad Jack]

So, I wouldn't start with reporting them to any agencies. I would start with your insurance company. They are at the heart of it obviously billing for services they did not provide, which would fall under fraudulently charging insurance, even if you're ultimately paying because you haven't met your deductible yet (because it's being applied towards your deductible). Call the member line for your insurance company and tell them you want to report fraudulent billing for a provider submitting charges for services they did not provide....even if they're telling you they're "waiving" the fees for now they still submitted the charges to the insurance company. If this goes anywhere, it may trigger an audit by the insurance company of this practice's records.

I would also make sure you record the start and stop times (take screenshots of the phone calls if it's just a phone call and not a telemedicine platform) and dates of any telemedicine appointments she has with them, so you clearly have a recorded trail of evidence which will show there is no way she spent enough time to do a psychotherapy add on code. It's not like she's even spending 20 minutes and trying to bill a 90833...she's billing a freaking 90838 which I'd expect to be triggering audits anyway but whatever.

You could also report her to the board of nursing in your state but that depends if you want to stay patients there or not...

If it's private insurance, you can't report them to CMS as far as I know because this is a private contract between the insurer and the practice, what this is is insurance fraud (same way if you claimed fire damage or said your car was stolen but it didn't actually happen...she's submitting a claim for a service she didn't provide).

Most states have an insurance commissioner that would be the one who handles these sorts of matters. For blatant fraud, personally I'd send it right to the commissioner and also report it to the insurance company.

 

[Dedzo99]

It seems the NP practices independently as my current state allows them to do so. As I digged deep, said NP listed psychodynamic psychotherapy, cognitive behavioral therapy, dialectical behavioral therapy, EMDR, mentalization based therapy, acceptance and commitment therapy, motivational interviewing, spiritual counseling and family therapy among their expertise in psychology today

100% insurance fraud.

Also lol im sure shes an expert in psychodynamic therapy. Probably doesnt even know the definition of the word transference.