The Next Generation of Multi-Discipline Practice Fraud

Multi-discipline fraud is evident in the rise of practices that were created by practice building consultants to avoid or eliminate limited chiropractic insurance coverage. They are often associated with an MD. This type of practice is now less popular due to increased scrutiny and investigative interest on the part third party payers as well as state regulators. Multi-discipline fraud is no longer a matter for an MD. It can be done by any physical therapist who is willing to accept reimbursement and not limit coverage.

It is important not to try and cover up fraud in multi-disciplinary practices. Providers care about patients and not just the bottom line. Most use due care to ensure that their practices comply with all laws and regulations regarding health care.

If it happens, it could be the next-generation multi-discipline fraud.

This practice is designed to maximize reimbursements for healthcare services. It involves (1) reporting similar services rendered by providers from different disciplines; (2) avoiding a limited insurance coverage for one provider by having another provider (covered) render the health care; or (3) allowing the provider not covered to bill for the rendered services under the license granted by the covered provider.

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Different practice names and tax identification numbers are used for each practice. They are based on the practice rendering care. This prevents detection by a provider with limited insurance that they are involved in the direction and control of health care services.

Patients are often seen in large numbers by the practice. This is usually due to extensive marketing of free services. Patients are informed that their health care will not cost them anything and that insurance will cover it. Patients are not told what amounts they will be charged and where the practice will collect a deductible, copayment, or co-insurance amount.

The services are provided based on the availability of insurance, not the patient’s medical needs. Tall patients receive the same treatment at a similar time, and the treatment continues even if the patient is in better health.

It is difficult to properly document the referrals of physicians to physical therapists, the physician’s review on the work of the physical therapy and/or physician referrals to the physical Therapist ordering services that are not being followed up by the physical.

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According to the practice, the patient sees multiple providers at once. This is where the provider reports that the patient has seen providers from different disciplines in order to receive health care services.

The practice reports on extensive physician exams, physical therapy evaluations that were not properly documented in the patient’s clinical record. This includes treatment plans that describe the type, frequency, duration of services provided to patients. It also indicates the diagnosis and expected goals.

The practice reports extensive electrodiagnostic testing, including range of motion testing, usually the next day after an exam/eval. There is little to no documentation as to twhy and how the testing was used in the treatment and care of the patient.

The practice reports services not fully and accurately documented in the patient’s clinical record taccount. This includes the activity, body area, intensity, duration, and time spent rendering time-based procedures and services.

The practice delegated the administration of services to unlicensed staff, despite the requirement that they be performed by licensed providers in direct one-on-1 contact with patients.

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According to the practice, there were many time-based services provided by staff with very few licensed providers. These services were either not required for 15 minutes increments without using appropriate modifiers or administered by staff who are not licensed.

This report reports services provided by one provider to another provider who is a disciplined provider and that are otherwise not covered.

The practice reports on health care services that were rendered to the same area by different providers during the same patient encounter.

Practice reports services that are not accurate reflections of actual service/procedure rendered.