It's a familiar scenario: A provider is accused of letting unqualified, improperly supervised employees perform services and billing for their work. They pay a stiff fine to resolve the allegations and have to deal with the embarassment of negative press. However, it is a scenario we associate with small practices. Perhaps an overworked solo doctor who lets a medical assistant perform services. It isn't what one would expect from a large health system with multiple locations and — one assumes — a robust compliance policy,
such as San Diego-based Scripps Health.
Scripps Health (Scripps), a health care system based in San Diego, California, has agreed to pay $1.5 million to resolve allegations that it violated the False Claims Act by charging federal health care programs for physical therapy services that were rendered by therapists who did not have billing privileges for these programs and were not supervised by an authorized provider, the Justice Department announced today [Jan. 19].
This Department of Justice press release should serve as a reminder to do two things:
1. Review the rules for superversion of services, including incident-to rules.
Medicare and TRICARE limit billing privileges to enrolled providers. Services from unenrolled providers can be billed as “incident to” the services of an enrolled physician, but only if the physician provided direct supervision. The United States alleged that Scripps billed Medicare and TRICARE for physical therapy services provided by therapists without billing privileges and without the appropriate supervision by a physician.
In some cases, state practice act supervision requirements may actually be more stringent than Medicare rules. If that’s the case, always follow the rules of your state practice act.
2. Listen to staff who come forward with concerns about compliance issues.
The settlement resolves allegations filed in a lawsuit by Suzanne Forrest, a former Scripps employee, under the qui tam provisions of the False Claims Act, which permit private individuals to sue for false claims on behalf of the government and to share in any recovery. The civil lawsuit was filed in the Southern District of California and is captioned United States ex rel. Forrest v. Scripps Health, Case No. 16-CV-0634.
According to the complaint, the government said that Forrest had warned Scripps it was out of compliance, but those warnings were not heeded. She resigned in 2015.
Forrest will receive $225,000 for her role in bringing the issue to the government's attention.