When it comes to claims and compliance, be payer agnostic

On Wednesday, June 20, 2018, VantagePoint HealthCare Advisors President and COO Susan Prior, CHC and Senior Consultant Regina K. Alexander, FACHE, CHC presented a live webinar, The Unknown-Unknowns of Credentialing, Privileging, and Enrollment for the Health Care Compliance Association (HCCA). The webinar drew a diverse audience, including attendees from hospitals, health systems, health plans, post-acute care, law and consulting firms. During the Q&A portion of the event, Susan and Regina responded to questions about use of locums, primary source verification for allied health professionals, and multiple questions regarding submitting claims when services have been rendered by a provider not yet enrolled.

A memorable question that bears follow-up and focus pertained to what was allowable when filing claims with commercial payers. The attendee acknowledged understanding it would not be allowable to substitute the name and NPI of a participating, enrolled provider in the 'rendering provider' box on the claim for a non-participating (or not yet enrolled) provider in respect to a claim submission to a government payer, and then asked if the same scenario is allowable with a private payer. The short answer provided on the webinar was a 'no', but the question itself reveals a more universal misunderstanding that healthcare providers can play by a different set of rules in their approach to private, commercial payers.

When it comes to claims and compliance, healthcare organizations should be payer agnostic in their attitude and approach to the basics, like the information reported on claim forms. While it's true that the Lincoln Law (False Claims Act) is enforced in respect to Medicare and Medicaid claims, the Health Care Fraud Statute (18 U.S.C. § 1347) applies to obtaining payment under false pretenses from both government AND private payers. Another consideration ancillary to submitting accurate claims is the claim as a secondary medical record. Medical records are legal documents and purposely altering the content of a claim in a manner that does not reflect the services as documented in the primary medical record could have implications under state laws. Lastly, commercial health plans build benefit structures to consider specific member-cost sharing in respect to out-of-network care. Provider groups and healthcare organizations can not only run afoul of contractual obligations by misrepresenting non-par provider services as rendered by a participating provider, if the plan is employer-sponsored, enforcement remedies are available under the  Employee Retirement Income Security Act of 1974 (ERISA).