Overpayment can happen for many reasons, including simple error. “But that doesn’t preclude the federal government or any payer from coming to the (doctor) and getting their money back,” Melnykovych said.
Sometimes the excuse is legitimate. Blount said if a doctor is affiliated with a teaching hospital – Schapira is a professor at the school of medicine at UCLA – that could explain a higher volume of patients at higher level codes. In his statement, Mace said that he is “currently on staff at Stanford.”
A spokesman for Stanford Hospital and Clinics said in an email to KQED that Mace is an “independent community cardiologist who has ‘courtesy admitting’ privileges at Stanford Hospital & Clinics. Dr. Mace is not on Stanford’s faculty.”
VanderMolen’s website says that he “has had several university, hospital, and other appointments.” It does not indicate any current affiliations with any academic medical centers.
Problems can also arise from the billing set up at a doctor’s office. Many doctors don’t do their own billing, Blount says. They dictate their office notes from a visit or fill out a checklist, and then a clerk in the billing department enters a code.
“Many times a physician is not even aware of what their claims are or how their claims are coded,” Blount says.
He has also seen a rising trend in unintended coding errors that mirror the rise of the implementation of electronic medical record systems. Many of these systems include an automated coding function. A physician will type in medical observations and treatment protocols, and then an algorithm will determine the code.
“Those algorithms are subject to human error,” Blount says. “Some mistakes are being made by the electronic medical record vendors in how they designed the product that they’re selling.”
Still, according to Medicare rules, the ultimate responsibility for billing always rests with the doctor.
It’s not just the total number of visits that could raise red flags among auditors — repeat complex visits by individual patients could also be a cause for concern.
Tue, May 20 2014