"There are two major reasons for you to confirm accuracy: to be sure that fraudulent claims are not being submitted and to confirm that the claims accurately reflect the work you have performed," write Ray Painter, MD, and Mark Painter.
Ray Painter, MD
In your coding and billing course, you suggested that all physicians should review their explanation of benefits statements to be sure that they were billing correctly. I work for a major hospital chain and I requested to review my EOBs for the past month, and the hospital billing department refused access. Do I have any legal recourse? Any suggestions?
We are not lawyers and do not attempt to answer legal questions. Although it is unlikely to be addressed in your employment contract, it might be, so our first suggestion is to check your contract to see if there are any restrictions or privileges granted to you that may allow you to change the discussion. Regarding your question on legal recourse, we are going to have to point you to a lawyer for a review of your contract and the obligations it entails.
Ultimately, you are responsible for what’s being submitted to the payer in your name, and you should be able to confirm its accuracy. From that standpoint, it is our belief that you would have a legal right to see what is being submitted to all payers in your name.
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Regardless of the legality, it is unfortunate and very short sighted for an employer to withhold that information. Therefore, we recommend that you check with management to be sure that is company policy and not just the billing department’s reticence. If your employer is truly focused on best practices for the system, they would encourage all physicians to be informed of all aspects of the practice that relate to production, especially accurate billing.
You are asking the right questions and should keep pushing. Most contracts we have seen include a base salary plus a productivity bonus based on relative value units. Although we have seen a few contracts that allow the RVUs for a physician to be based on CPT codes submitted to the billing department, most are based on the CPT codes actually submitted to the payers and paid.
Therefore, there are two major reasons for you to confirm accuracy: to be sure that fraudulent claims are not being submitted and to confirm that the claims accurately reflect the work you have performed.
Coding question? Contact Ray Painter, MD, and Mark Painter c/o Urology Times, at email@example.com.
Questions of general interest will be chosen for publication. The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.