In a climate in which third-party health care payers are looking for ways to reduce costs, speech-language pathologists and audiologists may feel pressure to maximize reimbursement for their employers, patients, or their own practices—and, perhaps, to consider unethical or illegal billing practices.
ASHA's Board of Ethics developed an "Issues in Ethics" statement, Representation of Services for Insurance Reimbursement, Funding, or Private Payment, to help SLPs and audiologists avoid situations that could be considered an ethics violation or fraud and abuse. The following questions are some of the key topics addressed in the statement.
Q. What are fraud and abuse?
Reimbursement fraud can be defined as any intentional deception or misrepresentation in an attempt to defraud a government agency—such as the Centers for Medicare and Medicaid Services (CMS)—or other third-party payers. Knowingly billing for services that were never rendered, for example, is considered fraud.
Providers commit abuse if they participate in practices that don't conform with sound business or health care standards and that lead to unnecessary reimbursement for services—even if the practices are unintentional. Abuse could include, for example, excessive charges for services or supplies, claims for services that aren't medically necessary, or improper billing practices.
Q. What specific behaviors related to reimbursement could result in an ethics challenge or charge?
ASHA's "Issues in Ethics" statement discusses six specific topics in detail and includes examples of concerning behaviors.
- Misrepresenting information to obtain reimbursement or funding, regardless of the provider's motivation.
- Providing service when there is no reasonable expectation that the patient will gain significant communication or swallowing benefit.
- Scheduling services more frequently or for longer than is reasonably necessary.
- Requiring staff in a prospective payment environment (acute rehabilitation, long-term care, or home care) to provide more hours of care than can be justified, so that the patient's care conforms to Medicare requirements for that setting.
- Supervision of students or other providers in a fee-for-service environment.
- Discounting care for reasons other than documented need by, for example, providing professional courtesies or complimentary care for referrals.
Q. What are key principles to keep in mind when documenting services for reimbursement and funding?
Information must be presented accurately and honestly, regardless of the potential reimbursement outcome or the motivation of the provider. Providers cannot justify unethical behavior even if it is for the benefit of the patient or the provider's employer. Additionally, it is the professional's responsibility to learn about and stay current on all applicable payment policies, rules, and regulations. Professionals put themselves at risk for charges of abuse when they make mistakes, even if the mistake results from the provider's unawareness of a rule or policy.
Q. Where can audiologists and SLPs go to understand the many reimbursement policies, rules, and regulations?
ASHA's billing and reimbursement website has extensive resources, guidelines, and policy statements on issues related to Medicare, Medicaid, private health insurance, and billing codes.
Contact the State Advocate for Reimbursement (STAR) or State Medicare Administrative Contractor (SMAC) network representative in your state for state-specific information.
Providers also should be aware of payer-specific policies. Local Medicare contractors, state Medicaid agencies, and other third-party payers all have different payment and coverage policies, and providers must be aware of those differences. Learn how to access their medical policies and coverage determinations. Sign up to receive updates and attend provider conference calls sponsored by the payers. It is providers' responsibility to stay current on all payers' policies.