O&P Facility Nightmare: One Bad Decision Can Sink the Ship

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By Teresa Presson

I had the pleasure of working at an O&P facility for 20 years. We provided excellent patient care and were well respected by our patients and the surrounding medical communities. Our staff adhered to the highest ethical standards of providing O&P care.

Unfortunately, sometimes when a patient is in a Medicare-type stay, the hospital or nursing home will refuse to issue a purchase order for O&P services. This leaves the O&P facility to decide if it should: (a) provide the service and disregard whether or not it will be paid; (b) not provide the service at all; or (c) provide the service and bill it on the date of discharge, even if it does not qualify for the two-day rule.

Our facility owner chose c. This is fraud.

Our company was investigated by the Federal Bureau of Investigation (FBI) for providing services and billing on the discharge date. I have heard many people say, "An investigation would scare me to death." If this happens to you, "scare me to death" takes on a whole new meaning.

We were subpoenaed twice for more than 1,700 charts, and each had to contain all of the original documentation, beginning with the patient intake sheet all the way down to the last receipt for payment on any claim that had been filed on each service. Our attorneys advised us to audit every Medicare payment we had received in a five-year time span and report to Medicare any payment that should have been paid by the hospital or nursing home. We audited more than 10,000 Medicare payments for legitimacy. Amidst all this, the business had to continue normal operation. We continued to take care of our patients, and the billing cycle process had to continue. We worked from 4:30 a.m. to midnight for several weeks. This process alone proved to be devastating-physically and psychologically.

The third subpoena was for me, the person who processed the paperwork. I had to appear before a grand jury for questioning and provide handwriting samples and fingerprints. According to the investigator, at this point I was a target. I was an O&P administrator, a manager. I was not the owner of the facility, nor the owner of the Medicare supplier number, but I was still a target. I sat before a panel of nine investigators for four hours of questioning.

The initial subpoena was served to our company in November 2004. The criminal part of this investigation was settled in October 2007. The civil investigation is in its final stages. The last I heard, there were talks of a proposed settlement of $1.4 million. This nightmare has lasted three years.

Thankfully the investigation team was not morally bankrupt. They took into consideration the fact that prior to the investigation I had several discussions with the owner in regard to not wanting to file Medicare for services that the hospitals or nursing homes should have been paying. I also had several discussions with hospital and skilled nursing facility (SNF) administrators/directors in regard to the Medicare rule for inpatient O&P services. Since there was clear evidence this was not done with willing malice, the investigation team agreed to allow the felony charge to be filed against the company-and not me. The company took the felony charge and is now dissolved. The investigator said that this is the first time they have ever allowed a felony to be put on the company and not the person.

To O&P facility owners who think they can't afford to lose a referral by not providing inpatient services and billing Medicare instead of the hospital when applicable: You can't afford to have that referral. It can cost you every dime you have, not to mention your certification and your business. My attorney fees alone exceeded $45,000, and I am sure the owner's attorney fees were much higher. These fees are never reimbursed. I am sure that no O&P owner would want to put any of his staff through a similar situation. I will never forget the day my owner sat before me, with tears in his eyes, and said, "I am so sorry. I would have never had this happen to you for anything."

To O&P facility directors/managers: You process it; you are responsible for it. The next person may not be as fortunate as I was. I feel blessed to sit here and compose this article in the luxury of my own room and not from a federal prison cell. Forget the expenses-the physical and psychological toll is beyond description. Believe it or not, I have heard an O&P owner state that he "is not worried about Medicare coming after him for any kind of fraudulent suspicions; they always go after the girls who process the claims." I hope you are never placed in a situation like that.

Teresa Presson is the president of Total Claims Billing, which provides billing and data/claims processing services to O&P practices.