Audit-proofing your ultrasound practice

Diagnostic imaging, once the exclusive domain of radiologists, has moved into other specialties, including obstetrics and gynecology. Ob/gyn residents are trained to perform and interpret ultrasound images, and most ob/gyn offices perform U/S examinations. The Coalition for Patient-Centered Imaging (CPCI) and the American College of Obstetricians and Gynecologists support offering imaging services in ob/gyn practices, on the assumption that these practices provide high-quality services conveniently to their patients.¹

Insurance companies have seen a substantial increase in diagnostic imaging costs and are now looking very closely at claims and utilization patterns. Some HMOs use imaging management firms, such as CareCore National ( http://www.carecorenational.com/), to review and authorize U/S studies. Other insurers, such as Aetna, have developed Clinical Policy Bulletins defining what current procedural terminology (CPT) codes the insurer will reimburse based on specific International Classification of Diseases (ICD)-9 diagnoses.² Insurers reject claims and deny payment for procedures performed outside these guidelines.

Some insurers review utilization patterns to determine whether aggregate U/S charges are higher than expected for a physician in that specialty. The findings can prompt an audit, which may show that a practice is not complying with accepted billing practices or even suggest fraud and abuse.

The OIG reports that the greatest potential for fraud and abuse involves:

The US Department of Justice can criminally prosecute fraud under certain federal statutes. The government can also seek substantial civil penalties under the False Claims Act,⁵ including triple the amount of oversubmitted charges and penalties of $5,500 to $11,000 per fraudulent claim.

An investigation can be started, not only by the OIG or Justice Department, but also by a disgruntled employee or patient acting as a "whistleblower" under what is known as qui tam relator legislation.⁶ A whistleblower-initiated investigation can also trigger an investigation under the False Claims Act. Qui tam relator legislation provides that the person who reports the claim (relator) may be entitled to as much as 30% of the money recovered plus attorney fees.

The OIG notes that physicians have a duty to ensure that claims are honest and accurate. The False Claims Act covers services billed but not actually provided and services performed but not medically indicated. Improper coding of procedures, specifically intentional coding errors or "deliberate ignorance," or "reckless disregard" of acceptable coding procedures, is a violation of the law. Court rulings have established that the physician is responsible for the accuracy of bills submitted in his or her name, regardless of whether the bill was completed by the physician personally or the office staff.⁷

Commercial insurers, as well as the government, can audit medical practices and request that payment be returned for overbilled or medically unnecessary procedures. In many states, they must report cases of suspected fraud to the state attorney general or department of public health for investigation. In Connecticut, the state insurance department asks health insurers to voluntarily report all fraud investigations they have conducted.

In October 2000, the OIG published guidelines for developing compliance programs in physician practices, noting that a compliance program is the best defense against illegal coding and billing. The full text is available in the Federal Register.⁴ The salient points include designating a compliance officer, conducting internal audits of billing (5 to 10 records per physician annually), and providing ongoing education for staff involved in billing.