Lacrivera

State auditor: Carlisle optometrist owes MassHealth $310,000 - Lowell Sun

While the first optometrist was a little aloof, what was done to the second optometrist was a hatchet job. That doctor provided excellent care, and one could argue above average care, and they just nailed them anyway.

My favorite travesty of justice was when the second optometrist personally paid to make glasses for people who needed it because the state lab was so far behind in delivering glasses, and the response of the state was “Oh you definitely owe us that money since you didn’t use our lab.”

I loved the “official letter” with all the so-called methodology which can easily be disputed, the avoidance of the state of answering legitimate objections, and the use of language to make the document sound as if it was indisputable.

If you ever get one of these letters, do not accept it; disputed it to the highest level and extract as much money and time as you can from them where they look at you as a porcupine they don’t want to bite because they will get hurt. The only way to stop these ridiculous audits is to make them pay and make them pay harshly where they go after easier prey.

If I were these optometrists, the public posting of this on the Internet may be a violation of their civil rights and I would consider a civil suit against the state of Massachusetts for at least 10 times the damages that they caused their practice due to impinging their reputation. As I said be a porcupine, not a freaking bunny rabbit OD.
 
Frederick Frost said:
what was done to the second optometrist was a hatchet job. That doctor provided excellent care...

My favorite travesty of justice was when the second optometrist personally paid to make glasses for people who needed it because the state lab was so far behind in delivering glasses
Click to expand...

Agree 100%.
It costs our office $6.95 to have the product [which was made incorrectly] sent back to be fixed vs making the cuts in house with same quality plastic lenses for $2.10. We also cut the turnaround time from 4-5 weeks to 20 minutes.
 
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I believe that Dr. Khuong Nguyen's billing patterns should be more deeply evaluated before we all make a judgement call on whether Dr. Nguyen was treated farily or not. With a total claim cost of over $500,000 during the period, Dr. Nguyen should have been aware that there would be some attention paid to the practice.

The letter used "dollar sampling" technique that is approved by the national body of internal auditing for an "...a statistically random sample of 180 out of 18,130 paid vision care claimsfrom the audit period, using an expected error rate of 50%, a desired precision range of 15%, and a confidence level of 95%, .." If the statistical analysis showed a variation from the norm, then it is justified in saying that the imcorrect (improper) billing would have been obvious.

The State of Massachusetts supported their assertion or allegations of poor practice by evaluationg the charts and found that there was insufficient documentation to support many of the complex decision making inherent in an E/M paradigm. The wisdom of E/M vs 92xxx coding is thus illustrated by this case. If you want to bill E/M, there are no short cuts for compliance on documentation.

Since Dr. Khuong is asking for public funds for the care of patients, it is presummptive that contract compliance would be necessary.

Note: The content within this post is neither medical, legal, or financial advice. Consult a qualified professional for your specific circumstance. It is my personal opinion and does not reflect the opinion of my employer. This also is not a solicitation.

#MyPersonalNonLegalOpinion #Tips4EyeDocs
 
Richard_Hom said:
I believe that Dr. Khuong Nguyen's billing patterns should be more deeply evaluated before we all make a judgement call on whether Dr. Nguyen was treated farily or not. With a total claim cost of over $500,000 during the period, Dr. Nguyen should have been aware that there would be some attention paid to the practice.

The letter used "dollar sampling" technique that is approved by the national body of internal auditing for an "...a statistically random sample of 180 out of 18,130 paid vision care claimsfrom the audit period, using an expected error rate of 50%, a desired precision range of 15%, and a confidence level of 95%, .." If the statistical analysis showed a variation from the norm, then it is justified in saying that the imcorrect (improper) billing would have been obvious.

The State of Massachusetts supported their assertion or allegations of poor practice by evaluationg the charts and found that there was insufficient documentation to support many of the complex decision making inherent in an E/M paradigm. The wisdom of E/M vs 92xxx coding is thus illustrated by this case. If you want to bill E/M, there are no short cuts for compliance on documentation.

Since Dr. Khuong is asking for public funds for the care of patients, it is presummptive that contract compliance would be necessary.

Note: The content within this post is neither medical, legal, or financial advice. Consult a qualified professional for your specific circumstance. It is my personal opinion and does not reflect the opinion of my employer. This also is not a solicitation.

#MyPersonalNonLegalOpinion #Tips4EyeDocs
Click to expand...

Richard -- what I find interesting about cases like these are that they are usually flagged b/c the doc is stepping far out of bounds of statistical norms, so their behavior is easy to pick up and scrutinize.

How much fraud/abuse/improper billing do you think is being hidden by docs sticking inside the fat part of the bell curve, and thus harder to see? Is the overall impact greater than those outliers?
 
Douglas Haigh said:
Agree 100%.
It costs our office $6.95 to have the product [which was made incorrectly] sent back to be fixed vs making the cuts in house with same quality plastic lenses for $2.10. We also cut the turnaround time from 4-5 weeks to 20 minutes.
Click to expand...
Yes, but he did seem to over bill.
 
AdminWolf said:
Richard -- what I find interesting about cases like these are that they are usually flagged b/c the doc is stepping far out of bounds of statistical norms, so their behavior is easy to pick up and scrutinize.

How much fraud/abuse/improper billing do you think is being hidden by docs sticking inside the fat part of the bell curve, and thus harder to see? Is the overall impact greater than those outliers?
Click to expand...

I believe (my personal opinion only!) that in today's statistical analytical program, there is rarely a situation that any particular provider's billing patterns are not known. Of course, it is also well known that the time it takes to prosecute someone for low transaction rate/amount is the same for someone who has a high transaction rate/amount in their claims. I think you can see who will be evaluated further for deeper analysis.

I also believe that an analysis can occur over an aggregate of providers in a partiuclar state or even within the provider's self for variations in billing patterns.

A good example is the prevalence of keratoconus. If the prevalence in the general popuilation of keratoconus is "1 in 2000" (Rabinowitz,1998), then it is variance from the norm that a provider is billing for keratoconus contact lens care (non-elective, or medically necessary) at a prevalence rate that exceeds 1 in 1000. Let's' also suppose that the aggregate optometrists is submitting claims for testing AMD at an estimated prevalence rate of 75% where the commonly accepted prevalence rate is 15% (Friedman et al., 2004).

if the provder has the appropriate documentation to support such care, then the provider could survive whatever audit that may occur. In summary, any particular provider cannot "hide" amongst the aggregate.

Note: The content within this post is neither medical, legal, or financial advice. Consult a qualified professional for your specific circumstance. It is my personal opinion and does not reflect the opinion of my employer. This also is not a solicitation. #Tips4EyeDocs

References:
Friedman, D. S., O’Colmain, B. J., Munoz, B., Tomany, S. C., McCarty, C., De Jong, P. T., ... & Kempen, J. (2004). Prevalence of age-related macular degeneration in the United States. Arch ophthalmol, 122(4), 564-572.

Rabinowitz, Y. S. (1998). Keratoconus. Survey of ophthalmology, 42(4), 297-319.
 
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AdminWolf said:
Richard -- what I find interesting about cases like these are that they are usually flagged b/c the doc is stepping far out of bounds of statistical norms, so their behavior is easy to pick up and scrutinize.

How much fraud/abuse/improper billing do you think is being hidden by docs sticking inside the fat part of the bell curve, and thus harder to see? Is the overall impact greater than those outliers?
Click to expand...
$500k over a 4-5 year period doesn't seem a lot to me. There are practices that do much much more in just Medicaid. Maybe it's very high for the MassHealth prison system. Hopefully the prison population is smaller compared to those on Medicaid. :) But it does look like the doctor was sloppy in his/her record keeping.
 
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