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Somerset Optometry Practice To Pay US Government $800000 To Settle False ... - LEX18 Lexington...

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Wow, that doesn't look good.

For those who practice in nursing homes, how do you determine the necessity for exams?
 
AdminWolf said:
Wow, that doesn't look good.

For those who practice in nursing homes, how do you determine the necessity for exams?
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Medical necessity for an examination is determined the same way it would be in our offices. Either there is a patient complaint, or you were doing an existing follow up, of a known medical condition that requires to be reviewed at a certain interval. (Glaucoma, dry eye, etc). Other reasons for a visit, could include a recent fall, or a sudden change in patient behavior which may be related to vision problems noticed by the staff.

Monthly visits on all nursing home residents would be extremely hard to justify. Assuming this optometrist did not actually mean to commit fraud, the thing I noticed that gets most people in trouble, is the level of code they bill, for the visit performed.

In the case of another gentleman down south, he performed code 99306, on approximately 180 nursing home residents in a single day. If you look at the documentation for this code, this is a level five office visit that Medicare thinks should take more than one hour to complete. I have noticed in that case, as well as this case, the doctors were investigated, for performing such a large number of codes in one day, that they possibly could not have given the necessary time, according to Medicare, to perform the examinations adequately, so they were cited. Drs should be aware, that Medicare is using this as a basis to audit doctors. While it is possible using auxiliary staff, to complete these codes in less time, a reasonable charge should be used on all patients, including nursing home patients. The vast majority of patients, I check are code 92012.


Fred
 
One other comment I would like to mention. The amount of money paid back in this case is not a large amount of money if the practice was going out to nursing homes daily, as it is over a five-year period and could represent just part of the amount of money that was actually billed to the program.

It is also possible, that the doctor in this case could be innocent. I hope that he is. No one should jump to the conclusion that he committed fraud.


Fred
 
Frederick Frost said:
Monthly visits on all nursing home residents would be extremely hard to justify. Assuming this optometrist did not actually mean to commit fraud, the thing I noticed that gets most people in trouble, is the level of code they bill, for the visit performed.
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I'd say level of code AND frequency of billing. Either will trigger an inquiry if they are notably out of the norm.

I'd also note that this is a Civil action, the government apparently deciding not to seek a criminal complaint. Thus, intent isn't going to be relevant.

That said, as we all know, if he was billing monthly 920xx claims, he's going to get caught. You might have patients with monthly 99212 or even 99213 claims, but not ALL patients in a nursing home.
 
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Sounds like someone I know's extern that got hit, but the doctor had to wait until he got back from his world cruise to write the million dollar check.
 
Steven Nelson said:
Sounds like someone I know's extern that got hit, but the doctor had to wait until he got back from his world cruise to write the million dollar check.
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I've known a number of OMDs that have been it with similar CIVIL issues with Medicare and/or Medicaid. I've not known one to go BK or lose their home because of it. They end up paying back a small percentage of what they've made.

In contrast, VSP typically demands back a multiple of what you've actually made from whatever they claim you've done incorrectly.
 
Craig Steinberg OD JD said:
I've known a number of OMDs that have been it with similar CIVIL issues with Medicare and/or Medicaid. I've not known one to go BK or lose their home because of it. They end up paying back a small percentage of what they've made.

In contrast, VSP typically demands back a multiple of what you've actually made from whatever they claim you've done incorrectly.
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Have you seen any ODs go bankrupt from a VSP audit?
 
AdminWolf said:
could be that his mode of practice is so different that he's worried that he'll stand out as an outlier...
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I'm already an outlier. All nursing home ODs are, but I'm comfortable with my protocols. I don't see anyone that the home doesn't specifically ask me to evaluate, my documentation is good and I don't see anyone any closer than a six month interval. Although most of my patients have significant eye disease, it's generally stable stuff that I'm monitoring for progression. Plus I'm careful in my coding, so I'm only doing one level 4 per year, only photographing changes, not pulling every lash I see, don't do many plugs...stuff like that.

What I DON'T want is the time, stress and expense of an audit because of clowns like this. A friend of mine went through a $250k audit and it cost him almost $40k in legal expenses. At the end, he didn't have to pay a dime back, but it still took up 8 months of his life, tons of time providing records and that $40k in legal fees. So, basically he was doing everything perfectly and it cost him $40k to prove it.
 
Steven Nelson said:
If you'd like to say something, just say it. Don't be a pussy and dance around it.
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When the target is on your back, as you jokingly said, you can respond to your investigator any way you want.
 
Russell Lee said:
Have you seen any ODs go bankrupt from a VSP audit?
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Yes.

I've seen several practices truly just close their doors and the doctors walk away.

Most OD's cannot pay VSP $250,000 or more. Imagine a 30-something that's been in private practice 5-10 years, making $100k/year, getting a demand for $150,000, due in 30 days.

Craig
 
Steven Nelson said:
I'm already an outlier. All nursing home ODs are, but I'm comfortable with my protocols. I don't see anyone that the home doesn't specifically ask me to evaluate, my documentation is good and I don't see anyone any closer than a six month interval. Although most of my patients have significant eye disease, it's generally stable stuff that I'm monitoring for progression. Plus I'm careful in my coding, so I'm only doing one level 4 per year, only photographing changes, not pulling every lash I see, don't do many plugs...stuff like that.

What I DON'T want is the time, stress and expense of an audit because of clowns like this. A friend of mine went through a $250k audit and it cost him almost $40k in legal expenses. At the end, he didn't have to pay a dime back, but it still took up 8 months of his life, tons of time providing records and that $40k in legal fees. So, basically he was doing everything perfectly and it cost him $40k to prove it.
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Like it or not, the reality is your mode of practice makes you an easy target for an audit, and it's almost a certainty and a cost of doing business. It helps if you can stay under the radar, but it's hard to do that if you're busy.

The key, the absolute key (and I'm saying this more for others than for you because you already know it) is GOOD documentation of what you've done, why you're doing it, CC, management plan, etc. That can end an audit relatively quickly. I've seen too many ODs that work in residential care and skilled nursing facilities get caught up in the CRAPPY record keeping and vague scribbles of most MDs. That's a trap. Write legibly. Write a lot. Spend the extra 45-60 seconds to be thorough in documentation. If you photograph, make a note that indicates how that's helpful with management of the patient (as opposed to just documenting the existence of the thing being photographed), such as, "monitor q6 mo, watch photos for change in appearance or size". Then it is self-explanatory to the 9th grade educated auditor.

Craig
 
Craig Steinberg OD JD said:
Yes.

I've seen several practices truly just close their doors and the doctors walk away.

Most OD's cannot pay VSP $250,000 or more. Imagine a 30-something that's been in private practice 5-10 years, making $100k/year, getting a demand for $150,000, due in 30 days.

Craig
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So what happens to those ODs who cannot pay the large fines of $250k or more?
 
Jeff Kiener said:
They have to work it off in the VSP labs. It's hard labor.
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Let's see...working at a VSP lab for $10/hour, 40 hours/week...$250,000 fine...paying tax on the $10/hour salary...eating only ramen...living in parents' basement for free...not spending a dime on anything else...roughly equals about 14 to 15 years at the VSP lab to pay off the fine.
 
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You can also be a server serving the lobster lunches at corporate to the office workers.
 
I'm always amazed that so many of these large scale frauds go undetected for years but I frequently get letters demanding that I refund them $7.23 for an overpayment made 16 months ago.
 
Ken Elder said:
I'm always amazed that so many of these large scale frauds go undetected for years but I frequently get letters demanding that I refund them $7.23 for an overpayment made 16 months ago.
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Exactly. If I file fundus photos and I'm only supposed to file the professional component (on some patients, the technical component is supposed to be billed under part A and you never know who until you get "the letter"), I get a letter almost immediately asking for ALL of it back.
 
Russell Lee said:
Let's see...working at a VSP lab for $10/hour, 40 hours/week...$250,000 fine...paying tax on the $10/hour salary...eating only ramen...living in parents' basement for free...not spending a dime on anything else...roughly equals about 14 to 15 years at the VSP lab to pay off the fine.
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Look on the bright side, it's a pay raise from what they are paying you now.
 
Frequency of billing is something that is always in the back of my mind. For example, I have a patient that works in a children's daycare center who presented 4 months ago with a classic bacterial conjunctivitis. 1 month later she returned with a viral conjunctivitis, many kid's in the daycare had it. She just returned this week with another viral conjunctivitis.

Obviously she is not taking my hygiene lectures to heart, but I am sure someone at her medical insurance is looking at the billing and going "Hmmm"
 
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