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"If you don't have systems in place to catch those kinds of mistakes, internal audits, that's where you get in trouble," he says. "The Fraud Enforcement and Recovery Act in 2009 expanded the False Claims Act so that not only are false and fraudulent submissions a violation of the act, but now if you have knowledge that you received an overpayment and you don't return that, the inaction can be a false statement. You have an obligation to act on that overpayment."
Selecting the right E/M code can be a challenge, and some providers think they are playing it safe by choosing a code with a value somewhere in the middle of high and low, Hollander says. They hope that by doing that they will stay under the radar with Medicare.
"By doing that they are flagging their claims by essentially telling Medicare that they don't know how to properly E/M code," she explains. "Submitting a flat line value for the codes stands out because Medicare is looking for standard distribution in a bell curve. Not every person in your practice is going to need the intensity of care, so not using the right E/M code doesn't keep you under the radar and instead it gets their attention."
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