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The Nine Deadly Sins of Fraud and Abuse in a Physician Practice Print E-mail
Written by Benjamin Frosch   
Sunday, 29 August 2010 12:25

In today's health-care climate, the mere hint of impropriety can lead to investigations and/or sanctions with respect to fraud and abuse. The following are nine "sins" or traps that can put a physician smack in the middle of a government false claims allegation:

1. Continue to take your time and/or ignore billing inquiries by patients or family members.

Don't make this foolish mistake. Take every phone call and inquiry pertaining to billing from patients seriously. Remember, every Medicare beneficiary gets an Explanation of Medicare Benefits (EOMB) that includes toll-free numbers to report allegations of fraud and abuse.

2. Make a foolish decision to "complete" your medical records after you've received an audit notice from Medicare or Medicaid. 

Changing and altering medical records are both illegal and unethical unless you clearly note that the change is an addendum to the original record. Then, at a minimum, record the date you entered this change or added additional information to the medical record.  Clearly make sure that Medicare and or Medicaid is aware of your modification and when it occurred.

3. Rely on information that “Charlene" at Medicare told you.   

Now that you've verbally received billing information from "Charlene" at Medicare customer service, create a paper trail confirming the information. Document the phone call and ask Charlene where you can find the information she advised you was published, i.e., in Medicare websites, Medicare bulletins, or other literature. It's a good idea to document every call you make to Medicare. Include the issue, who you spoke to, the date and time. Do not just take her word for it. Confirm her information before billing Medicare.

4. Permit staff to re-bill all denied services for medical necessity by resubmitting a "covered" ICD-9 code without any documented clinical reason.  

This policy speaks for itself and if caught could become a nightmare. Especially when your billing staff is telling government agents it was your idea.

5. Bill for someone else's services under your provider number without full compliance of the "incident to" provision.  

With respect to physician assistants, nurse practitioners or medical assistants, there is very strict and to-the-point criteria for billing services rendered "incident to" by these individuals under your provider number. Billing hospital visits performed by your PA or ARNP under your provider number is a big no-no. The "incident to" provision was not intended for the hospital setting. If it is a true "shared visit”, the services must be medically necessary.

6. Be proud of your compliance violations. 

Brag in the doctors' lunchroom about billing all of your E&M service as level four and five visits or submitting false diagnoses to get claims paid. Some colleagues within hearing shot may get angry and advise the government of your excellent billing skills.

7. Keep purchasing diagnostic services and marking them up without letting the carrier know. 

This can cause serious problems as Medicare regulation strictly prohibits marking up purchased diagnostic services. Additionally, Medicare issued regulations and guidelines that clearly indicate how the claim is to be submitted. You must indicate on the claim what the cost of the purchased service was (to avoid a mark up), who you purchased the technical component from and meet other requirements. There are also strict rules for billing purchased interpretations. Make sure you comply with all the Medicare rules when billing globally for an interpretation you did not perform 

8. Become a  Medical Director of a  Home Health Agency, Durable Medical equipment Company, or any other Designated Healthcare Service that you refer heavily to.

Make sure you are paid exceptionally well and have no documentation demonstrating your "Medical Director" services. Most important never have seasoned healthcare lawyers review these types of Medical Director relationships or other arrangements.

9. Now that Lebron James, Dwayne Wade, and Chris Bosh are all on the Miami Heat, feel comfortable taking those great (and expensive) Miami Heat playoff tickets from healthcare providers you refer to.

After all, who would ever think that those tickets are related to your referring patients to them? You will just tell the OIG agents that you only refer patients based on "quality" and those tickets would never skew your judgment.


Benjamin Frosch is President of Frosch Medical Consultants, Inc. in Plantation, FL.


Last Updated on Saturday, 04 May 2013 15:22
MEDICARE Q&A: Mid-Summer Update Print E-mail
Written by Benjamin L. Frosch   
Sunday, 25 July 2010 13:48

Q:   I am a solo practitioner who specializes in cardiology.  One of the tests that I perform in my office is echocardiography.   During very busy periods, I may not provide a full interpretation and report of my echocardiograms for a few months.  I understand that I cannot bill Medicare until the service is complete and therefore wait until I have provided a full interpretation and report.  As a result, I may not bill Medicare for those services for over a year period.  Has there been a change with respect to the time period of submitting claims to Medicare?


Tampa, FL

A:  As a result of the Affordable Care Act (ACA), the Centers for Medicare and Medicaid Services (CMS) will only pay for claims with dates of service on or after January 1, 2010 up to a year. Claims received later than one calendar year beyond the date of service will be denied by Medicare.  Therefore, you should not submit claims to Medicare that are more than one year old.  

Another point that you should consider is that by taking so much time to interpret these echocardiograms, Medicare could take the position that these services were not medically reasonable and necessary in treating and managing the patient.   So even if you submit claims for echocardiography on or after January 1, 2010 and forward them to Medicare months after performing the echocardiogram, you may still have an issue pertaining to why you waited so long to interpret those echocardiograms. 


Q: We have a Locum Tenens physician who next week will be with us for sixty days.  It is our understanding that sixty days is the Medicare "cutoff" for a locum tenens physician which allows us to use the Q6 modifier.   The provider enrollment process is very cumbersome and I was wondering that once our Locum Tenen physician reaches the sixty day period, can the Locum Tenens Physician take a day off and the sixty day Medicare period begin again?

Office Manager

Palm Beach, Fl

A:     If the regular physician requires services of a Locum Tenens physician for a period longer than sixty days, the substitute physician needs to enroll with the group practice.   The Locum Tenen physician should complete a CMS 855R reassigning his/her benefits to the practice.   Otherwise, the substitute physician "taking a day off" is not a consideration in the Medicare guidelines of Locum Tenens for establishing the sixty day period.  

CMS guidelines state that a regular physician may bill for the services of a Locum Tenens physician providing that the following guidelines are met:

A.    The regular physician is unable to provide visit services.

B.   The substitute physician does not provide services over a continuous period longer than sixty-days.

C.    The Medicare beneficiary has arranged for or seeks to receive services from the regular physician.

D.    The regular physician pays the Locum Tenens for services on a per diem or similar fee for time basis


Q:  I am a non-participating surgeon. I performed a surgery on a Medicare beneficiary that was very complex and time consuming.   Because the claim was submitted unassigned, the beneficiary received the payment which was very low for the surgery performed. The patient is elderly and would have difficulty filing an appeal.  Can I file the appeal on behalf of the beneficiary?


South Florida

A:  Yes,under certain circumstances. The beneficiary may complete an appointment of representation form (CMS 1696) which can be found at  This form is used to authorize an individual to act as a beneficiary's representative in connection with a Medicare appeal. As a representative, you would be able to help your Medicare patient during the processing of the claim and any subsequent appeals.


Q:  We tried to provide our patients with the highest quality of care. For our established patients, we have started to treat them on an "emergency" basis after hours at our office.  Is it necessary for us to attach modifier 25 (indicating a significant, separately identifiable E/M visit on the same date as another procedure) to our follow-up visits in order to additionally bill Medicare procedure code 99058 (services provided on an emergency basis in the office, which disrupts other scheduled office services in addition to basic service)?

Office Manager

Boca Raton, Fl

A:   CPT code 99058 is not a recognized service that is billable to the Medicare program.   The E&M follow-up visits will have to be billed according to the actual level of care that is provided to the patient.  There is no additional reimbursement by Medicare for disruption of other scheduled services or after hour services in your office.     



Last Updated on Sunday, 14 August 2011 14:11
Medicare Q&A: Early Summer Update Print E-mail
Written by Ben Frosch   
Monday, 05 July 2010 15:01


Q:  We are a group practice that uses non-physician providers such as physician assistants and nurse practitioners.  We still are unclear pertaining to appropriate billing of spilt/shared visits between a physician and non-physician practitioner.   Using Medicare guidelines can you define a split/shared visit and provide an example?

Administrator, Medical Practice

Broward County, FL

A:  According to Medicare guidelines, a spilt/shared visit is a medically necessary encounter with a patient where the physician and qualified non-physician practitioner such as a physician assistant or nurse practitioner each performs a substantive portion of the evaluation and management visit, face-to-face with the same patient on the same date of service. A substantive portion of an E/M visit involves all or some portion of the history, examination, and medical decision making components of the E/M service.   Simply signing off on the non-physician provider's note does not meet the criteria for a spilt/shared visit.

An example of a spilt/shared visit is a hospital inpatient E/M service that is shared between the physician and non-physician provider.  In this scenario the non-physician provider  and the physician both provide components face-to-face of the E/M encounter with the patient at separate times during the day.  This service may be billed under the physician or the non-physician provider's National Provider Identifier (NPI).

Q:  I understand that direct supervision is required to comply with "Incident-to" provision".  If a physician is in the suite, can an initial/new patient visit be billed under the physicians NPI when the service is completely provided by a nurse practitioner?


Fort Lauderdale, FL

A:  The main requirements for a provider to bill "Incident-to" are as follows:

·The services are an integral, although incidental, part of the physician's professional service;

·The service is commonly rendered without charge or included in the physician's bill;

·the service is furnished in the physician's office under the physician's direct supervision;

In order for the service to qualify as "incident-to", an initial office visit must have occurred between the physician and the patient, and a course of treatment is established by the doctor.  In the initial office visit you describe, the services are performed by the non-physician provider and do not meet the "incident-to" requirements although you are available in the suite.   You never saw the patient and therefore cannot have a plan of treatment.   Therefore, the non-physician provider would need to bill this initial encounter under their NPI number.

Q:   I employ two nurse practitioners and provide nursing home visits throughout Palm Beach County.  Can the nursing home visits provided by nurse practitioners be billed as "incident-to", a supervising physician as long as the physician is also in the facility seeing patients? 

General Practice

Palm Beach, FL

A:  The "incident-to" provision does not apply to institutional settings such as hospitals and nursinghomes. It is possible in the hospital setting for the physician and nurse practitioner to provide a shared/ spilt visit and bill it under the physicians NPI number if all the guidelines are met. Shared visits rendered in the nursing home cannot be billed to Medicare.   The only exception to this is when the physician is renting space from the nursing home and has his/her own office within the facility. In this scenario; the office space must be confided to a separately identifiable part of the facility.  Your staff may provide services in the office to out-patients and meet all of the components of the "incident-to" provision including direct supervision in order to bill under your NPI.   In the event that your non-physician provider employee provides these services outside of the office area, these services would not qualify as "incident-to" 

Q:  Last week, a patient of mine was diagnosed with hypertension and placed on a regiment of medication and diet.  I also wrote in my plan of treatment that the patient should be seen times-three (x3) in the office by my physician assistant to access the patient's progress.  I understand that if I am available and provide direct supervision, that this service can be billed under my NPI.   If I am not in the office when the service occurs but my partner is in the office, is the physician assistant visit eligible for "incident-to" billing?

Internal Medicine

Miami, FL

A:  Yes, the physician assistant visit is eligible for "incident to" billing. According to Medicare's guidelines, direct physician supervision in a clinic or office may be the responsibility of several physicians, as opposed to an individual attending physician. The physician who initiates the course of treatment doesn't need to be the same physician who oversees the physician assistant performing an incidental service.  The service you described may be billed under your partner's NPI who is physically in the office suite and providing direct supervision at the time of the service.

Benjamin L. Frosch, is the President of  Frosch Medical Consultants, Inc. in Plantation, FL

Last Updated on Sunday, 14 August 2011 16:56
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