Health Care: Consultants' Billing Advice May Lead to Improperly
Paid Insurance Claims (27-JUN-01, GAO-01-899T).
This testimony discusses the results of GAO's investigation
concerning health care billing consultants who conduct seminars
or workshops that offer advice to health care providers on how to
enhance revenue and avoid audits or investigations. Consultants
at two workshops that GAO attended provided in-depth discussions
of regulations that pertain to billing for evaluation and
management health care services and compliance with health care
laws and regulations. Certain advice provided during those
discussions is inconsistent with federal law and guidance
provided by the Department of Health and Human Services' Office
of Inspector General. Such advice could result in violations of
both civil and criminal statutes. Specifically, certain
consultants advocated not reporting or refunding overpayments
received from insurance carriers after they were discovered. The
consultants also encouraged the performance of tests and
procedures that are not medically necessary to generate
documentation in support of bills for evaluation and management
services at a higher level of complexity than actually confronted
during patients' office visits. Also, GAO is similarly concerned
with statements about billing practices made by a private
consultant it also contacted. This testimony summarizes the June
report, GAO-01-818.
-------------------------Indexing Terms-------------------------
REPORTNUM: GAO-01-899T
ACCNO: A01266
TITLE: Health Care: Consultants' Billing Advice May Lead to
Improperly Paid Insurance Claims
DATE: 06/27/2001
SUBJECT: Health care programs
Overpayments
Health insurance
Consultants
Billing procedures
Fraud
Program abuses
Medicaid Program
Medicare Program
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GAO-01-899T
HEALTH CARE Consultants' Billing Advice May Lead to Improperly Paid
Insurance Claims Statement of Robert H. Hast Managing Director Office of
Special Investigations
United States General Accounting Office
GAO Testimony Before the Committee on Finance,
U. S. Senate
For Release on Delivery Expected at 10: 00 a. m. EDT Wednesday, June 27,
2001
GAO- 01- 899T
GAO- 01- 899T
Mr. Chairman, Ranking Minority Member, and Members of the Committee: I am
pleased to be here today to discuss the results of our investigation
concerning health care billing consultants who conduct seminars or workshops
that offer advice to health care providers on how to enhance revenue and
avoid audits or investigations. My testimony today is based on our recent
report of that investigation, which you are releasing today. 1 Accompanying
me today are Dr. Kathryn Locatell, a physician we contracted with to assist
us on this investigation, and William Hamel, a criminal investigator with my
office.
In summary, consultants at two workshops we attended provided in- depth
discussions of regulations that pertain to billing for evaluation and
management health care services and compliance with health care laws and
regulations. Certain advice provided during those discussions is
inconsistent with federal law and guidance provided by the Department of
Health and Human Services? Office of Inspector General (OIG). Such advice
could result in violations of both civil and criminal statutes.
Specifically, certain consultants advocated not reporting or refunding
overpayments received from insurance carriers after they were discovered.
The consultants also encouraged the performance of tests and procedures that
are not medically necessary to generate documentation in support of bills
for evaluation and management services at a higher level of complexity than
actually confronted during patients? office visits. Furthermore, one
consultant suggested that providers discourage patients with low- paying
insurance plans, such as Medicaid, from using their services by limiting
services provided to them and scheduling appointments for such patients at
inconvenient times of the day.
In addition, we are similarly concerned with statements about billing
practices made by a private consultant we also contacted. This consultant
claims to have a large client base. We did not incorporate the private
consultant?s remarks into our report due to time constraints; however, Dr.
Locatell will discuss the consultant?s statements in her testimony today.
If followed, the advice provided at the two workshops we attended would
exacerbate program integrity problems in the Medicare and Medicaid programs
and result in unlawful conduct. Moreover, the advice raises concerns that
some payments previously classified by the Department of Health and Human
Services? OIG as improperly paid health care insurance claims may actually
stem from conscious decisions to inflate claims by providing unnecessary
services or manipulating documentation in an attempt to increase revenue. We
have discussed with the OIG the need to monitor workshops and seminars
similar to the ones we attended.
Mr. Chairman, at this time, Mr. Hamel will play excerpts from the tapes we
recorded at the workshops and during our discussion with the private
consultant. He will also explain the context under which these recordings
were made. We will then answer any questions that you or other members of
the Committee have.
1 See Health Care: Consultants? Billing Advice May Lead to Improperly Paid
Insurance Claims (GAO- 01- 818, June 27, 2001).
GAO- 01- 899T 2 GAO Contacts
For further information regarding this testimony, please contact Robert H.
Hast at (202) 512- 7455 or William Hamel at (202) 512- 6722.
(600909)
*** End of document. ***