In an attempt to go after No-Fault Insurance Fraud, New York State and Gov. Andrew Cuomo are seeking to expand current regulations regarding the information that physicians and clinics are required to provide. The expansion would include provisions that will bar suspected providers from participating in, and billing for, services under the No-Fault regulations of New York State.
According to a non-public “list” of suspected providers held by the office of Governor Cuomo, over 100 providers have been initially targeted. Letters are being sent to providers demanding certain information in connection with the investigation. The State has made it clear that such information can be turned over to the Department of Health (OPMC – Office of Professional Medical Conduct) and the Education Department (OPD – Office of Professional Discipline) for the purpose of bringing potential professional misconduct allegations against any physicians and other providers, whom they consider to be engaged in fraudulent activities for action to be taken against their license. Such information might also be shared with other government enforcement agencies.
Providers need to be aware of their rights, and what they are required to do and provide in light of the regulations, should they receive such letters. In many cases, proper planning to make sure that a practice complies with relevant laws and regulations is important prior to any investigation.
These days with the state of the economy as it is, it should come as no surprise that insurance companies and HMOs are being even more aggressive at auditing than they have traditionally been in the past and attempting to take back payments for services rendered from physicians and health care entities.
While the health care industry as a whole might be growing, the providers reimbursement that the provider gets to keep is shrinking. There are some tactics and approaches that can be used by a health care provider that can not only protect them from improper allegations of fraud and abuse made by an insurance company during an audit, but even help the provider increase revenues in their practice if there is no audit, since it can serve as a means to supervise their own practice policies and find any shortfalls in billing and coding that could be costing them money.
Every physician and health care provider has heard of the term “fee splitting”. Unfortunately, few really look beyond the most simplistic application of the prohibition, a mistake that could have serious consequences for their career as fee splitting is a violation of professional misconduct regulations.
An allegation of fee splitting is more likely to arise in a dispute with a third party such as an insurance company, independent contractor, or an employee than it is by direct investigation by the Department of Health or Department of Education. This exposes a provider to a greater risk since an adversarial party is the one bringing it to attention of the Office of Professional Medical Conduct (OPMC) or Office of Professional Discipline (OPD in the case of a non physician health care provider).
Any arrangement where one party’s compensation or contract fees are based on a percentage of a provider’s revenue is likely to fall under fee splitting prohibitions. There are limited exemptions, one of the most common being partners/shareholders/owners of a professional organization or professional employee’s incentive bonus (providing they are the same license). Non-professionals do not have a license to lose and are not affected by an allegation for professional misconduct based on fee splitting. As laypeople the OPMC and OPD have no authority over them, so physicians and other health care providers must be extra cautious when dealing with them.