05/01/2017    Steven J. Kaniadakis, DPM

Healthcare Fraud 101: Under False Claims Act - Part 1

Poppycock. The government and investigators do
not tell you until it is essentially too late.
Besides a Grand Jury Indictment, which is held
without you, the Indictment will take on a
different context once at trial. An indictment
outlines charges against the defendant. However,
it may read that the coding business practice is
to follow the A.M.A's C.P.T code book "a five
number code".

When the defendant gets to trial then the coding
expert will say, 'the (AMA's) CPT code book is
not as pure as it looks". Now, here is how a
defendant really may find out how coding issues
are interpreted and given "color". Typically the
paid expert will not be the color in favor of
your meaning of the AMA's code book. Or, even the
AMA's view point for that matter.

The key is to not get into factual disputes about
coding issues. Stick to the legal issues. Did the
defendant get "more money than otherwise entitled
to receive", which is the statue for healthcare
fraud. The statue is the legal matter not the
factual disputes. So, do not waste resources on
to find out not the factual (coding) disputes.
Find how much money would the third-party
administrator or insurance company have paid
using the correct code.

Now here is the bad part. Even if you did not get
paid then it could be considered "attempted
fraud". What is worse? Mail fraud. It will be an
illegal act once you have mailed or submitted an
electronic submission like even by FAX
transmissions. Articles like this can make
podiatrists think they are not committing a
potential crime or send podiatrists down the
wrong pathway.

Steven J. Kaniadakis, DPM, Saint Petersburg, FL

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