Sunday, October 14, 2007

I was reminded today of an event that occured in my career 14 years ago. I was in the midst of preparing to transition out of my solo practice into a group practice. Rather than invest in a new practice management system, I chose to contract with a billing service earlier in the year.

As I was nearing the end of my preparations I received a call from the local CMS intermediary (in those days, Medicare intermediary)....They wanted to send to me a series of HCFA 1500 forms for laser surgeries they said came from my office. About a week later a group of claims arrived in an envelope. I was a little bit mystified, since I did all of my billling electronically and also accepted assignment, which conflicted with the HCFA 1500 forms I received to review. I called the intermediary and said I had no idea what this was about, repeating my comments given above......They also asked if it was my practice pattern to perform 8 laser surgeries in one week on the same patients. They had about ten such claims for different patients. Upon my review, none of these claims were for any of my patients. Not only that but none of them lived in the Riverside California area. I sort of forgot about the whole thing, and it was almost a year later that I received a call from the U.S. Attorney in Los Angeles asking for me to appear before the Grand Jury....that was a heart stopper! By this time I was living and practicing in Georgia.

I could see the headlines...."local ophthalmologist leaves California as a federal fugitive." This is the type of thing that often occurs to me. You know when Medicare looks for "fraud and abuse" the first one that comes to mind is the doctor... During one of my telephone "interviews" I was asked to supply a photo of myself....I became more nervous.

I knew I was off the hook when the attorney told me they would pay my travel and boarding expenses for the trip. They apparently had a "sting" operation which netted a "gang" of thieves.

The story gets even more humorous, except that it was a true story. Upon my being sworn in to testify, the attorney told the grand jury that "the doctor is not a suspect, but a material witness"

My heart flipped over in relief. It was in the record officially... He went through a succession of disclosures and physical evidence ranging from the billling forms, to cancelled checks in glassine envelopes inlcuding the fact that many of the billings occured after I had ceased practicing in Riverside. It seemed the gang had accessed my medicare provider number via a source at the billing service. And I was not the only one, although their billings from me amounted to 850,000 dollars this was pocket change compared to the overall scheme. The offender was cornered at the Santa Anita Raceway attempting to cash a check endorsed by "me". The suspect when questioned stated that he had been asked by me to cash the check....He was shown a group of photos one of which was the photo I had sent to the FBI. Fortunately he did not pick my picture as the "doctor"... The moral of this story is that you should guard your medicare number, NPIN number, and password access to your CAQH identification and authorization to access your files. These numbers are akin to your credit card.

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