Ask the Expert

Ask the AOPA Expert: Avoiding Medicare Fraud
By Virginia Torsch, AOPA Government Affairs Department

Q: I have been told that I cannot hire any practitioner who has been excluded from participating in Medicare. Is this true?

A: Yes. In fact, the rules on enrolling as a Medicare supplier specifically state that a Medicare supplier cannot employ, or have a contract with, any individual or business that has been excluded from participation in any federal health care program. So before you hire a practitioner or do business with another company (such as a central fabrication lab or a hospital), check to see if they are on the exclusion list maintained by the Department of Health and Human Services' Office of the Inspector General (OIG). You can search a database of individuals and businesses on the list at this Web site: http://oig.hhs.gov/fraud/exclusions.listofexcluded.html.

Q: Why would someone be placed on the exclusion list?

A: A provider, practitioner or business would be placed on the list if convicted of Medicare or Medicaid fraud or abuse. A state licensing authority can also decide to place someone on this list if that provider is found guilty of violating state licensing laws.

Q: What happens if I hire someone who is on the exclusion list?

A: You could lose your Medicare supplier enrollment status. You could also face a fine of up to $10,000 for each item or service furnished by the person or business, an additional assessment of up to three times the amount of the claim for that item or service. Worse yet, Medicare could take the additional step of placing your facility on the exclusion list as well. For these fines to be imposed, the OIG has to show that you knew or should have known that you were hiring or doing business with someone on the list. The OIG expects that you will check the exclusion list before you hire someone or contract with another business, so the OIG will not accept the excuse that you didn't think to check.

Q: I suspect that one of my competitors is committing Medicare fraud. How do I alert the Medicare program?

A: You can report suspected Medicare or Medicaid fraud or abuse by contacting the OIG's hotline:

Phone: (800) HHS-TIPS (1-800-447-8477)
Fax: (800) 223-8164
E-mail: HHSTips@oig.hhs.gov
TTY: (800) 377-4950
Mail: Office of Inspector General Department of Health and Human Services
Attn: HOTLINE
330 Independence Ave., SW
Washington, DC 20201

Q: I don't want my competitor to find out I am reporting him. Can I report anonymously?

A: Yes. Even though the OIG does encourage you to provide your contact information in case they need more information about your initial complaint, the OIG will allow you to remain anonymous. You should indicate this desire in your phone call or letter

Q: What information do I need to provide if I call the Hotline?

A: You will be asked to provide the following information:

• Type of complaint (e.g., Is it about a Medicare Part A or B claim or a Medicaid claim?)
• The HHS program affected by the complaint (e.g., Medicare, Medicaid, or other)
• Your contact information (optional)
• Detailed information on the facility or person you are complaining about (name, facility name, address)
• A brief summary of the allegation of fraud or abuse.

Q: I provide orthotic services for a local hospital and my contacts there are asking me to change the delivery date of a brace I provided to the day before discharge. If I do this, am I committing fraud? Is the hospital committing fraud by asking me to change the delivery date?

A: The answer to both questions is yes. If you delivered a brace for use while the patient was in the hospital and the date was clearly at least 48 hours before discharge, the hospital is responsible for paying you for that brace as part of its consolidated billing. So if the hospital is asking you to deliberately change the date and bill your DME Medicare Administrative Contractor, then the hospital is asking you to commit fraud. The hospital is committing fraud as well, because it knows it should pay for the brace. No matter how tempting it is to acquiesce so that you can continue to do business with the hospital, don't. Remember the potential consequences if Medicare audits you and determines you have committed fraud.

Virginia Torsch is assistant director of government affairs at AOPA. Call her with your coding and billing questions at (571) 431-0812, or e-mail vtorsch@AOPAnet.org

Through reimbursement, coding and compliance education, AOPA works to inform and support the practice of O&P for the entire profession.