Coding and Billing

Coding & Billing: Why Some ODs Cheat & How to Avoid Breaking the Law

By Mark Wright, OD, FCOVD,
and Carole Burns, OD, FCOVD

July 11, 2018

A New Jersey optometrist pleaded guilty to one count of health-care fraud on September 18, 2017, and was sentenced to serve 33 months incarceration and pay a $25,000 fine. In addition, the judge ordered him to make restitution of $95,667 to Highmark Inc. and $3,333 to Davis Vision.

What was his crime? He admitted he submitted fraudulent claims for services that were never provided to patients, he submitted claims for the same services to both Highmark and Davis Vision, and he submitted fabricated treatment records to justify his fraudulent billing.
What are the three powerful lessons can we learn from this case?

1) Never submit claims for services or materials that were not provided to patients.
2) Never submit claims for the same services to different insurance companies.
3) Never fabricate treatment records.

We all know that these actions taken by this New Jersey optometrist were not just wrong, they were illegal. But is knowing that something is illegal enough to stop an eyecare professional from an illegal act? There is an interesting article titled “Why do people do illegal things when they know that these things are illegal?” Here is the list of reasons the article provides:

• Some people’s moral code is different than that of mainstream society (as represented by the criminal law).

• Some people think it’s better, or easier, to get ahead through crime than by earning an honest living.

• Some people are in desperate straits and do desperate things to survive (e.g. an addict who robs, steals, deals or prostitutes themselves to fund their next “hit”).

• Anger management, mental health and substance abuse issues are prevalent themes in the criminal courts.

• Some people are very poor at decision-making, and focus on the “here and now” rather than “is this really a smart idea?”

An even more exhaustive list can be found in the article “27 Psychological Reasons Why Good People Do Bad Things.” Here’s a summary of five of the key ideas in that article:

Tunnel vision: Single-minded focus on goals can blind people to ethical concerns.

The power of names: The use of nicknames and euphemisms for questionable practices can free them of their moral connotations, making them seem more acceptable.

Acceptance of small theft: When small thefts are ignored, so are slightly larger ones like over-claiming expenses or accepting unauthorized business gifts. It doesn’t take long for people to begin expanding the theft.

Reactance theory: Rules are designed to prevent unethical behavior, but when they’re seen as unjust or excessive they can provoke the opposite reaction.

Cognitive dissonance and rationalization: When people’s actions differ from their morals, they begin to rationalize … and the longer the rationalization lasts, the less immoral it seems.

Always remember that coding and billing has legal consequences. Always do the right thing. Always reach for excellence.

Click HERE to read more about the New Jersey OD found guilty of health-care fraud.

 

References
i. https://www.justice.gov/usao-wdpa/pr/optometrist-sentenced-33-months-prison-health-care-fraud-involving-least-250000-losses
ii. https://www.quora.com/Why-do-people-do-illegal-things-when-they-know-that-these-things-are-illegal
iii. http://www.businessinsider.com/27-psychological-reasons-why-good-people-do-bad-things-2012-8

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