Every so often, a new product, service, or billing opportunity comes along that sounds like a great fit for a practice. Maybe a vendor says it is covered by Medicare. Maybe someone recommends a billing code that produces surprisingly good reimbursement. Maybe you hear that other practices are already doing it.
That does not necessarily mean there is a problem. But it might mean it is worth asking a few more questions.
A recent federal appellate court decision involving a chiropractic practice offers a good example of why.
What Happened?
In United States v. Musselman, the U.S. Court of Appeals for the Seventh Circuit reviewed a healthcare fraud conviction involving an integrated chiropractic and medical practice.
Among the issues raised in the case were services billed under physicians who had not performed them, an adhesive device billed using a code for an implantable device, and sublingual allergy drops billed under a code associated with injections. The court ultimately upheld the conviction.
We are not sharing this case to criticize another chiropractor or to suggest that every coding error is fraud. Billing and coding can be complicated, and the facts of this case were extensive.
What makes the decision worth considering are the warning signs that appeared along the way. They are the kinds of warning signs that could show up in almost any healthcare practice.
Red Flag #1: The Numbers Make You Stop and Look Twice
One of the products discussed in the case reportedly cost the practice about $500 or less and took only a few minutes to apply. Medicare reimbursement was approximately $6,500. Staff questioned it.
High reimbursement does not automatically mean that something is being billed incorrectly. But when the numbers are surprising enough to make you wonder how they can be right, that is probably a good time to find out.
Before adopting a new billing strategy, ask a basic question: Does the code we are using accurately describe what we are actually providing? If you are not sure, verify it before submitting the claim.
Red Flag #2: The Coding Advice Comes From Someone Who Benefits From the Answer
Vendors know their products. They can explain how something works, how other practices use it, and what their customers are doing. That does not necessarily make them the best source for determining how Medicare should be billed.
This was an important issue in the case. The court discussed advice the practice owner received from people connected to the products being used. The opinion also noted that she had previously been cautioned about relying on product vendors for coding advice.
There is nothing wrong with asking a vendor how other practices handle billing. Just recognize the difference between a suggestion from someone selling a product and independent coding or compliance guidance.
If reimbursement is part of the sales pitch, it is worth independently confirming the information.
Red Flag #3: Someone on Your Team Is Asking, “Are We Sure About This?”
Another part of the case that deserves attention is that employees raised concerns.
That can happen in any practice. A biller notices something unusual. An office manager questions a code. A staff member says the reimbursement does not seem to make sense.
Those questions can be inconvenient, particularly when everything seems to be working and claims are getting paid. But they can also be an important safeguard. You do not have to assume the employee is right. You do need to find out.
Red Flag #4: Everyone Is Relying on Someone Else
Practice owners delegate. They have to. You may rely on an employee to handle billing, an outside billing company to submit claims, a consultant to advise the practice, or a vendor to explain a new product.
The problem comes when everyone assumes someone else checked. The biller thinks the consultant verified it. The consultant received the information from the vendor. The practice owner assumes the billing company would flag anything that was not permitted.
It is worth asking: Who actually verified this, and what did they rely on? There should be an answer.
Red Flag #5: “I Didn't Know” Becomes the Defense
One of the more significant parts of the appellate decision involved the concept of deliberate ignorance, sometimes called willful blindness. In simple terms, the issue is whether someone can avoid responsibility by choosing not to confirm something they strongly suspect may be wrong. The court found enough evidence in this case to allow the jury to consider that question.
That does not mean an honest billing mistake is the same thing as fraud. It isn't. Nor does it mean practice owners must personally become Medicare coding experts. It does mean that warning signs matter.
If the reimbursement seems extraordinary, employees are raising concerns, the coding does not seem to match the service being provided, or the only reassurance is coming from someone who benefits financially from the arrangement, it may be time to dig deeper.
A Few Questions Worth Asking
Before implementing an unfamiliar billing strategy, product, or service, consider asking:
- Does the code accurately describe what we are providing?
- Have we checked the actual Medicare or payer requirements?
- Is our information coming from an independent source?
- Has anyone on our team raised a concern that has not been fully answered?
- Can we explain why we believe this billing approach is appropriate?
- Do we have documentation showing how we reached that conclusion?
You may confirm that everything is perfectly appropriate. And that is a good outcome, too. The point is not to be suspicious of every new opportunity. It is to recognize when something deserves a closer look.
Why a Case From Illinois Matters in New York
This particular case arose in Illinois and was decided by the U.S. Court of Appeals for the Seventh Circuit. New York is within the Second Circuit, so the decision should not be viewed as a New York-specific ruling. Medicare, however, is a federal program.
More importantly, the practical lesson does not depend much on geography: if something about your billing makes you stop and think, “Is this really right?”, do not ignore that instinct.
Ask the question. Check the source. Get qualified advice when you need it. Sometimes the best way to protect your practice is simply to be willing to ask one more question.
NYSCA members can find additional Medicare, insurance, reimbursement, and practice resources in the Member Resource Hub.
This article is provided for general educational purposes and should not be considered legal, coding, billing, or compliance advice.