Your Billing Person Won’t Be Sitting Next to You in Court

Many nurse practitioners assume that billing is someone else’s responsibility. After all, they hired a billing company, outsourced revenue cycle management, or delegated claims submission to a trusted employee. Unfortunately, federal regulators do not see it that way.

This week, the Department of Justice announced what it called the largest healthcare fraud takedown in history, charging 455 defendants, including doctors, nurse practitioners, and other licensed healthcare professionals in connection with more than $6.5 billion in alleged fraudulent claims. The cases involved a wide range of healthcare settings, including wound care, telehealth, home health, behavioral health, and hospice. Federal authorities emphasized that they are increasingly using sophisticated data analytics to identify suspicious billing patterns before claims are even paid. (Department of Justice)

One of the most alarming aspects of these cases is that many of the healthcare professionals charged were not necessarily the people pressing the “submit” button on the claim. Their names, credentials, and provider numbers were attached to the services being billed. That alone was enough to place them under the microscope. In one case announced as part of the takedown, a nurse practitioner was allegedly connected to millions of dollars in Medicare billing while she was incarcerated and unable to provide patient care. (Department of Justice)

As nurse practitioners, we often wear multiple hats. We are clinicians, business owners, employers, and leaders. When the practice is busy, it can be tempting to trust that the billing department is handling everything correctly. But delegation does not eliminate responsibility.

Federal investigators routinely take the position that providers have a duty to know what is being billed under their names. If services are upcoded, billed without proper documentation, medically unnecessary, or never provided at all, the government is unlikely to accept “my billing person did it” as a defense. In many cases, providers face civil penalties, criminal investigations, licensing board complaints, exclusion from Medicare and Medicaid, and damage to their professional reputations. (Department of Justice)

This does not mean you need to become a certified coder. It does mean you should understand the fundamentals of your billing practices. Review your claims data. Conduct periodic audits. Ask questions when reimbursement patterns seem unusual. Make sure documentation supports the services being billed. Verify that incident-to billing, split/shared services, telehealth visits, and supervising provider requirements are being followed correctly. If something does not make sense, do not assume someone else has already checked it.

I often hear healthcare professionals say, “I hired experts for that.” Hiring experts is smart. Blindly relying on them is risky.

Think of it this way: if a medication error occurs because someone else administered the drug, the Board of Nursing still expects the nurse to understand what was ordered, why it was ordered, and whether it was appropriate. Billing is no different. The government expects providers to exercise oversight over the claims submitted under their licenses and provider numbers.

The recent healthcare fraud takedown serves as a reminder that regulators are paying close attention. The technology used to identify unusual billing patterns is becoming more sophisticated every year. What may have slipped through the cracks a decade ago is now being flagged automatically. Federal officials have made it clear that they are moving away from a “pay and chase” model and toward proactive detection of suspicious claims. (Nurse.org)

At the end of the day, your license is one of your most valuable assets. Protect it by understanding how your practice gets paid. Review your billing. Ask questions. Verify compliance. Because if there is ever an investigation, your billing company may become a witness, but you are the one whose name is on the license.

This topic also ties directly into Board of Nursing discipline. Even when a billing issue begins as a Medicare or insurance matter, it can quickly become a licensure issue when allegations of fraud, dishonesty, or unprofessional conduct are involved. That is a risk every nurse practitioner should take seriously.