Management & Compliance for Large/Academic Pathology Practices
Part 8 -
Practices of Business Consultants
Black-Schaffer & Johnson
OIG SPECIAL ADVISORY BULLETIN - Practices of Business Consultants
Office of Inspector General, HHS, 06/27/01 Special Advisory Bulletin: Practices of
Business Consultants. http://oig.hhs.gov/fraud/fraudalerts.html
Encouraging Abusive Practices.
Some consultants may knowingly encourage abuse of
the Medicare or Medicaid programs. In some cases, reimbursement specialists or other consultants
advocate that their clients engage in aggressive billing schemes or unreasonable practices that are
fraudulent or abusive of the Medicare or Medicaid programs. This conduct potentially subjects both the
consultant and the client to liability under the False Claims Act.
- The False Claims Act
ascribes liability only where the party knows or acts with reckless disregard or deliberate ignorance of
the falsity of the claim.
- A reimbursement specialist may suggest that a client use inappropriate billing codes in order to elevate reimbursement and may describe methods to avoid detection.
- A consultant may encourage a client to modify or customize a routine medical supply in an insignificant manner to justify billing the supply as a device that generates higher reimbursement.
- A reimbursement specialist may advise a client to bill for an expensive item or service with a high reimbursement rate when a less expensive item or service with a lower reimbursement rate was actually provided to the patient.
- A consultant may advise a client to adopt a patently unreasonable interpretation of a reimbursement law, regulation, or rule to justify substantially greater reimbursement.
- A consultant may promise to increase Medicare revenues for laboratory services by showing its clients how to disguise double billings and claims for medically unnecessary services.
- A consultant may suggest the creation of deceptive documentation in order to mislead potential reviewers.
Discouraging Compliance Efforts.
Some consultants may
make absolute or blanket statements that a client should not undertake certain compliance efforts (such
as retrospective billing reviews) or cooperate with payor audits, regardless of the client's
As reflected in the OIG's compliance
guidances,* the OIG believes that voluntary compliance efforts, such as internal auditing and
self-review, are important tools for doing business with the Federal health care programs.
Left undetected and, therefore, unchecked and uncorrected, improper billing or
other conduct may exacerbate fraud and abuse problems for a provider in the future.
Consultants who abuse
their position of trust pose a risk to their provider clients, to the Federal health care programs, and
to themselves. While most consultants are honest and provide valuable services to their clients, a small
minority engage in questionable practices or promote abuse of the Federal health care programs. In
general, if a consultant's advice seems too good to be true, it probably is. We urge providers to be
vigilant and to exercise judgment when selecting and relying on consultants.