Part B News Quotes Paul Werner on How Practices Can Protect Themselves from Financial Mischief by Third-Party Billers

Buttaci, Leardi & Werner member Paul D. Werner was quoted in an article in Part B News titled “Third-Party Biller Fraud May Hook Your Practice, Unless You Protect Yourself.” The article, published November 25, discusses the case of a third-party biller who was charged with healthcare fraud and entered a plea agreement – but the practice he worked for was not charged.

According to the plea agreement from the Northern District of New York case, the medical biller, who, as a consultant, was working as an office manager to a medical practice in Plattsburgh, “altered [the] level of service billing codes selected by the treatment provider to a higher-level reimbursing code without consulting with the provider.”

While the entirety of the scenario is not known, Werner tells Part B News that he has seen situations in which “a physician is riding off into the sunset of his career and allows someone to come in and de facto run the practice,” which can result in the administrator committing financial mischief without the provider paying attention.

“When a medical provider contracts with someone to provide billing services,” Werner says, “that provider is generally not looking at the paid claims — they’re mainly interested in claims that are not being paid.”

Werner suggests providers, who are always able to get access to their Explanation of Benefits, conduct reviews of relevant billing materials even if everything looks rosy.

“They don’t just tell you what you got paid; they tell you what you got paid for. So, if you know, for example, that your office policy is never to bill higher than a level three E/M and you spot check and find a lot of level fours or fives, you know there’s something wrong.”

Read the full text of the article at Part B News (subscription required).

• Posted on: Jan 2 2025