1. Dollars & Cents of Billing & Coding Mistakes

2. Agenda The Real Cost of Claims
Potential Penalties with the False Claims Act

3. Coders Can Pay for Coding Mistakes
The Federal False Claims Act (FCA) imposes liability on any “person” who knowingly submits a false claim to the government for payment or who “conspires” to submit a false claim for payment.
Source:

4. Coders Can Pay for Coding Mistakes
That could include coders who ‘knowingly’ cause false claim submission” and individuals who participate in fraudulent submissions, if those individuals are part of the actions that resulted in the false claim. This can include individuals who are responsible for “preparing, computing, calculating and submitting to Medicare claims for” medical services provided by a physician.
Source:

5. Coders Can Pay for Coding Mistakes
For example, the United States vs. Cabrera-Diaz and Arbona, 106 F.Supp.2d 234,242 (D. P.R ). In the Arbona case, Dr. Manual A. Cabrera-Diaz, an anesthesiologist, falsely submitted over $400,000 in Medicare billings in and His “billing secretary,” Esther Arbona, prepared and submitted Dr. Cabrera- Diaz’s claims. The U.S. District Court entered a civil judgment against both Dr. Cabrera-Diaz and Ms. Arbona for $1.3 million and found that they were “jointly and severally liable,” which means that the total amount of the judgment could be collected from either of them.
Source:

6. Protect Yourself From Monetary Liability
Read the fine print before you sign any contracts with employers to be sure there aren’t any embedded financial penalties within.
To protect yourself from coding error fines you should always code from the documentation and follow the coding guidelines.
Source:

7. Protect Yourself From Monetary Liability
As a coder, you should not append any code to a claim that is not supported by the documentation. If you assign the wrong codes because maybe you code from memory or you use a cheat sheet, then you are responsible for that code and it was intentionally applied.
Source:

8. Everybody Pays for Improper Coding
 U.S. Department of Health & Human Services (HHS) is taking a more proactive role for reviewing, paying, and monitoring Medicare reimbursements in the context of program integrity. In addition to the Office of Inspector General (OIG), the prime fraud and abuse overseer, other federal program integrity contractors and state enforcement agencies, have implemented initiatives to detect and investigate health care providers who submit false claims.
Source:

9. Everybody Pays for Improper Coding
The OIG’s compliance program guidance for physicians advises to fully document their services and implement compliance programs to reduce coding errors and ultimately, financial risk. The OIG’s guidance redefined the term “erroneous claims” to assure physicians that the OIG is not looking for enforcement actions against practices for innocent billing mistakes.
Source:

10. Everybody Pays for Improper Coding
For example, episodic and isolated coding mistakes are not targeted, but continued misapplication of coding and billing rules either because the coding professional is cutting corners on accepted practices (i.e., coding standard only from documentation) or not keeping up to date (i.e., continuing education), can lead to an OIG enforcement action. This being said, ultimately, liability falls to the provider whose National Provider Identifier (NPI) the service was billed under and not the coder directly.
Source:

11. Annual Cost of Coding Mistakes
Up to 70 percent of coding errors are caused by operator error, with almost half caused by mistakes in code entry and job selection.
Source:

12. Annual Cost of Coding Mistakes
Cost of coding errors in this example turned out to be a huge 17% of total running costs.
Traditionally, running costs have held the center of attention for competitive justification and cost saving projects. In reality, there are far greater rewards to be had from eliminating coding errors through Code Assurance measures. Error prevention opportunities are realized through continuous improvement in data handling and capability.
Source:

13. False Claims Act The Knowledge Requirement
A person does not violate the False Claims Act by submitting a false claim to the government; to violate the FCA a person must have submitted, or caused the submission of, the false claim (or made a false statement or record) with knowledge of the falsity.
In § 3729(b)(1), knowledge of false information is defined as being (1) actual knowledge, (2) deliberate ignorance of the truth or falsity of the information, or (3) reckless disregard of the truth or falsity of the information.
Source:

14. False Claims Act Definition of a claim
The FCA also defines what a claim is and says that it is a demand for money or property made directly to the Federal Government or to a contractor, grantee, or other recipient if the money is to spent on the government’s behalf and if the Federal Government provides any of the money demanded or if the Federal Government will reimburse the contractor or grantee.
Source:

15. False Claims Act Damages and penalties
After listing the seven types of conduct that result in FCA liability, the statute provides that one who is liable must pay a civil penalty of between $5,000 and $10,000 for each false claim (those amounts are adjusted from time to time; the current amounts are $5,500 to $11,000) and treble the amount of the government’s damages. Where a person who has violated the FCA reports the violation to the government under certain conditions, the FCA provides that the person shall be liable for not less than double damages.
Source:

16. DOJ Announces Dramatic Increase in False Claims Act Penalties
After August 1, 2016 whose violations occurred after November 2, 2015
Minimum $11,000 to a maximum of $21,563

17. False Claims Act - FAQ
What are the types of false claims under the False Claims Act?
One may submit a claim to the government which, on its face, contains false or fraudulent information-the "classic" false claim.
An example would be billing Medicare for laboratory tests that were never actually performed.
Source:

18. False Claims Act - FAQ Continued
One may use a false document in order to get a false or fraudulent claim paid or approved. 
For example, if a defense contractor submits a written certification declaring that certain tests were performed on equipment manufactured for the Army, but in fact those tests were never performed, and the certification is relied upon as part of the payment process, then a violation of Section 3729(a)(2) has occurred.
Source:

19. False Claims Act - FAQ Continued
The FCA addresses conspiracies to engage in any of the acts forbidden by the Act in Section 3729(a)(3).
Section 3729(a)(7), contains the so-called "reverse false claim" provision.  
An example would be a government contractor that falsely accounts for the value of government property in its possession to avoid having to compensate the government.
Source:

20. False Claims Act - FAQ
What is the definition of "knowing" under the False Claims Act?
The amended Act now mandates that a person (including any health care provider or contractor) can be held liable if it submits or causes to be submitted a false or fraudulent claim or a false statement in support of a claim:
a. with actual knowledge that it is false (' 3729(b)(1));
b. in deliberate ignorance of the truth or falsity of the information (' 3729(b)(2));
c. or in reckless disregard of the truth or falsity of the information (' 3729(b)(3)).
Moreover, Congress clarified that no proof of specific intent to defraud is required. (' 3729(b)(3)). One of the most grievous mistakes counsel unfamiliar with the FCA make is to equate the scienter requirement of the FCA with criminal fraud statutes.
Source:

21. False Claims Act - FAQ Continued
Not only does the statute state on its face "no specific intent" is necessary, it offers three varying definitions of "knowing" which do determine the scienter requirement. 
 actual knowledge ['3729(b)(1)], is entirely straightforward. If a false claim is submitted, or a false or fraudulent document submitted, and the submission is from a person who knows the document or claim is false or fraudulent, then a knowing submission has occurred. 
Source:

22. False Claims Act - FAQ Continued
A good illustration of acting in deliberate ignorance of the truth or falsity of information (section b(2)) is found where, for example, a physician practice does not properly supervise or train its billing staff, so that inappropriate claims are submitted.
The practice cannot avoid liability by asserting that it relied upon the billers if it could have exercised appropriate supervision over them; the same is true of independent billing companies. 
Source:

23. False Claims Act - FAQ Continued
Acting in "reckless disregard," is very difficult to assess. 
An example might be using a computer billing program for Medicare billing that has not been updated for five years to see, nonetheless, how many claims would be paid.
Source: