Highmark, Ultra reports and Medicare Audits – handle them by yourself at your own risk (or, why smart Doctors lawyer up) June 1, 2011
Posted by jefhenninger in Articles.Tags: Medicare Audit, Medicare Fraud, ULTRA Report
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Medicare is a pain to deal with. That’s why you love your billing manager so much right? Well, if you get a letter from Highmark indicating that an ULTRA report shows an aberrancy in your practice with regard to certain billing codes, I suggest you call a good Medicare fraud lawyer right away. The problem with the initial letter from Highmark is that is not really that threatening. It just lets you know that there is an issue. For the most part, you don’t really have to even do anything; there is nothing to even fill out. You could just file it away and ignore it right?
That could be a huge mistake. Sometimes after the letter with the ULTRA report, you will be targeted for an audit. The audit starts with a request for medical records for approximately 25 to 35 patients or services. These medical records will be reviewed internally which will generate an analysis that either supports your utilization or determines that the services were not covered for a variety of reasons, i.e., medical necessity, failure to abide by policies such as mandatory surgical second opinions or some other cause such as fraud. You will then be permitted to submit additional information which can then be submitted to an outside reviewer. Clearly, the big issue here is whether it appears that you are billing for services that did not occur or that you are intentionally over billing.
When records are requested, you should an attorney helping you through the process. The records you initially supply will be used to determine whether you will be subject to a refund request and further review. This could be your last opportunity to present all of the information necessary to support your actions in an attempt to avoid a costly audit and investigation. Your attorney should help you decide what to say and how much information to provide although it generally helps to provide as much information as possible but the records have to be organized and easy to read/understand. Your attorney may also have the records reviewed by an outside reviewer to bolster your position that your actions/practices are correct.
Please keep in mind that Medicare and Highmark can/will use the records that you have provided as a sample to generate refund requests covering the three year period prior to the services. For example, if 20 services are reviewed and it is determined that 10 of those services were unnecessary, then you may be subject to a refund request for 33% of all of the money that was paid for you for those services for the prior three years. That could be a very large sum of money.
Of course, you can and should speak to your attorney about disputing the ULTRA report and not waiting for the audit. First, review the ULTRA report to make sure that you are correctly characterized with regard to specialty as your practices are compared to your peer group (i.e. other physicians in your specialty). I’ve had cases where Highmark’s ULTRA report was not correct because my client had a very unique practice and thus, the peer group was not correct. You then need to review your billing practices with regard to those procedure codes in order to defend your practices or to revise that practice. In other words, assume you had to testify tomorrow. Would you be able to explain everything you did or your billing manager does? Are all of your records in order? Could you prove everything as if the burden of proof was on you? You also want to see how far above the 95% percentile you are. The closer you are to being off the charts, the greater the danger for not only an audit, but also a fraud investigation or prosecution.
Remember, even if you are found not guilty, your reputation is too important to risk. Don’t handle this yourself. Call a good attorney right away.
New Jersey Medicare Fraud Lawyers
Why Congressman Anthony Weiner was not hacked and why he claims he was June 1, 2011
Posted by jefhenninger in News.Tags: Congressman Anthony Weiner
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Unless you live under a rock, you have most likely heard that about the Anthony Weiner twitter scandal. Updated info is here. The latest now is that he cannot deny that the picture is him which is basically saying that the pic is really him. After all, if you took a picture of your crotch, wouldn’t you remember it? Wouldn’t you be able to identify your body parts in a picture? Exactly. So, lets assume that the pic is him.
If Congressman Weiner’s story is true, you would have to believe that he has a pic of his crotch just sitting on his computer. Then, he would have had to have left his computer on but unattended. Some hacker then uses a Trojan horse or some other method to hack into his computer. This evil hacker, who can do anything to this computer and access any file, decides to go through his pictures. Out of all of the information on this computer, this one picture is the key piece of information that the hacker seizes upon. Now the hacker has to decide what to do with it. I know, says the hacker to himself, I’ll open up his web browser and see, if by chance, he has saved any of his passwords. What luck, the Congressman saved his twitter password so that he can be automatically logged in. At this point, the hacker can then take over the twitter account and post all sorts of crazy things. Nope, the hacker would rather send the image to some random girl, Gennette Cordova, (who just happens to be pretty) that follow him on twitter. After that, the hacker clearly feels as if he/she has accomplished everything there was to accomplish and then he/she moves on without creating any other havoc. Then, the Congressman quickly learns of the evil deed and tweets that he has been hacked. All of this sounds a little crazy, huh?
If you are thinking that there may be other options here as to how this could have occurred, consider these points:
1. The picture clearly seems to be him. Thus, there is no way a hacker would have gotten into this computer and then separately hacked into the twitter account.
2. The twitter account is a verified account and if hacked, twitter would have pulled the account.
3. If twitter itself was hacked, it would have called in the FBI to investigate. Furthermore, as a soon to be public company, their security is important.
4. The hacker would have changed the password.
Clearly, Congressman Weiner cannot admit to sending a picture of his crotch to some young woman. It would ruin his career and probably ruin his new marriage. He screwed up and got caught. His story is crazy but you cannot prove him wrong as he will not allow anyone to have access to the evidence that can prove his story. I find it odd that a Congressman is permitted to go on TV and lie (more so than normal) and just get away with it. Twitter has to be concerned at some point here as they do not want the public to think that their system is not secure. They plan to go public sooner or later and they do not need a Congressman telling the world that his verified account was not secure.
In the end, the media should stop playing into the theory that he could have been hacked. He wasn’t. He did it. Let’s move on.
