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Thread: is this fraud? Arizona

  1. #1
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    Default is this fraud? Arizona

    Arizona outpatient clinic


    Hello.


    A new policy at work requires radiology techs to perform imaging in excess of what the RX requests. If the patient states he/she thinks he/she MIGHT have had a fx in the past (not documented by a licensed provider), we are told to perform more imaging which consequently changes the billing code from the code on the RX. Obviously this is done to bolster revenue.

    Most of the patients who require this type of imaging are on medicare/medicaid. Is this fraud? I am worried this could be a lawsuit in the waiting or at least a reason to protect my license.

    Thank you so much in advance.
    Last edited by Nepenthean; 03-17-2015 at 07:09 PM.

  2. #2
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    No this is not fraud, as the tests being billed are actually being performed and it is being done in order to provide better and more comprehensive care to the patient. Fraud would be if you were billing for the more comprehensive tests but not actually doing them.
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  3. #3
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    Quote Originally Posted by ElleMD View Post
    No this is not fraud, as the tests being billed are actually being performed and it is being done in order to provide better and more comprehensive care to the patient. Fraud would be if you were billing for the more comprehensive tests but not actually doing them.

    Thank you for the prompt reply.

    I spoke with a state regulator who said this action was illegal. This person said I should call the US Dept of Health and Human Services. This person also said if I could obtain specifics the regulatory agency would make an unannounced visit and begin an audit.

  4. #4
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    Ok then - contact them & let them investigate re anything illegal being done.
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  5. #5
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    This is definitely illegal under federal healthcare laws and regs (promulgated by CMS and HHS) and most likely under the state's law.

    The investigative and enforcement authority for cases like this is the office of Inspector General (OIG) of the US Dept of Health & Human Services.
    Performing and billing for diagnostic tests that were not prescribed is "fraud", but the term used in "false claim" (really another word for healthcare fraud).

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