Mobile radiology providers, and particularly those that serve patients in hospice, nursing home, and home health settings, are increasingly being targeted in Medicaid fraud investigations. Is your company at risk?
For most mobile radiology providers, billing Medicare is both an essential source of income and a primary source of administrative and compliance concerns. Unfortunately, while mobile radiology providers serve an essential function in bringing diagnostic tools to patients who are unable or have difficulty traveling to their doctor’s office or the hospital, they are also key targets in the federal government’s fight against Medicare fraud.
Why is this the case? In many respects, it has to do with the relationship many mobile radiology providers form with hospices, nursing homes, and home health agencies. Senior care has traditionally been one of the areas of practice in which Medicare fraud and abuse have been most prevalent. And as a result, companies such as mobile radiology providers are getting caught up in large-scale federal investigations as well. If Medicare auditors or federal investigators find any evidence suggesting the existence of an improper fee-based relationship or other abuse of the Medicare system, federal prosecutors will in turn aggressively pursue civil or criminal charges against all entities and individuals that appear to be involved.
7 Common Medicare Fraud Allegations against Mobile Radiology Providers
When facing a Medicare audit or federal investigation, mobile radiology providers must aggressively combat the auditors’ or investigators’ assumptions and allegations. In our experience, some of the most-common allegations against mobile radiology providers include the following:
1. Illegal Referral Fees
Under the Anti-Kickback Statute, it is a federal offense to offer, pay, solicit, or accept a referral fee or any other form of “remuneration” in exchange for a patient referral involving Medicare-reimbursed services. Investigations targeting alleged improper fees are particularly common where mobile radiology providers routinely work with the same physician(s) or have established relationships with hospices, nursing homes, and home health agencies.
2. Conspiracy to Commit Medicare Fraud
The federal conspiracy statute allows prosecutors with the U.S. Department of Justice (DOJ) to pursue criminal charges against mobile radiology companies and other healthcare providers, even in circumstances in which no improper billing has occurred. Federal prosecutors also routinely use conspiracy allegations as leverage to solicit information about third parties in large-scale Medicare fraud investigations.
3. Billing and Report Discrepancies
Discrepancies between what mobile radiology providers bill to Medicare and what they report to patients and their caregivers are red flags for auditors and investigators. While these discrepancies are often inadvertent, this does not stop prosecutors from pursuing severe penalties under the False Claims Act’s civil enforcement provisions.
4. Excessive Imaging
“Excessive imaging” refers to taking more images of a patient’s area of injury than are necessary to provide an accurate medical diagnosis. Even if a mobile radiology provider is forced to take multiple images of the same body part from the same angle due to a patient’s lack of cooperation or inability to stay still long enough to obtain a readable image, taking a large number of images of any one patient in a single visit or over a short period of time is likely to raise questions for auditors or investigators.
5. Medically-Unnecessary X-Rays
In addition to excessive imaging, other reimbursement requests for multiple x-ray images will often draw scrutiny under Medicare as well. Medicare will only pay for images that it deems medically-necessary, and multiple images or images unrelated to a physician’s order are unlikely to meet this criterion.
6. Imaging without a Physician’s Order
In order for any imaging service to be eligible for Medicare reimbursement, the service must be provided pursuant to a valid physician’s order. To be considered valid for Medicare billing purposes, a physician’s order must:
- Be from a licensed medical doctor or doctor of osteopathy;
- Be for a patient who is under the doctor’s care for the medical condition that requires imaging; and
- State the need for mobile radiology services.
In addition, the physician who orders the imaging must actually use the image results for purposes of managing the patient’s medical condition. If any one (or more) of these conditions are unsatisfied, then the mobile radiology service is ineligible for Medicare reimbursement.
7. Billing and Coding Violations
In addition to Medicare billing violations that are unique to the mobile radiology practice, portable service providers can face allegations of various other billing and coding violations as well. In fact, it is not unusual for a Medicare audit or investigation to result in numerous allegations of violations such as upcoding, unbundling, phantom billing, and double-billing.
Medicare only covers four components of mobile radiology services. Any reimbursement requests that fall outside of these components have the potential to trigger allegations of billing and coding fraud:
- Transportation of radiology equipment to the patient’s location;
- Equipment set-up;
- Administration of the scan; and
- Interpretation of the scan results.
Learn more: Mobile Radiology Services Fraud Defense : An Overview
Legal Defense for Mobile Radiology Providers Accused of Medicare Fraud
For mobile radiology providers facing Medicare fraud allegations, engaging experienced and strategic defense counsel is the key to avoiding unnecessary consequences and mitigating the risk of going to trial in federal court. At Oberheiden, P.C., we have extensive experience representing mobile radiology providers across the country, and our defense team is led by federal defense lawyer, Nick Oberheiden, PhD. Dr. Oberheiden is a staunch and unwavering advocate for his clients. His proactive and strategic approach to defense representation has one goal: favorable results before charges get filed.
Are you facing a Medicare audit or investigation? Are you concerned that a referral relationship or billing practice could expose you to civil or criminal prosecution? If so, it is important that you speak with an attorney as soon as possible. To schedule a free and confidential initial consultation with federal defense attorney, Dr. Oberheiden, please call (888) 356-4634 or request an appointment online now.
Dr. Nick Oberheiden has successfully represented healthcare executives and physicians – as well as businesses in the areas of toxicology, pharmacy, home health and hospice centers, DME, hospitals, surgery centers, neuro-monitoring, and blood and DNA testing centers – in healthcare compliance and defense.