United States General Accounting Office

Health Care Consultants' Billing Advice May Lead to Improperly Paid Insurance Claims

In summary, the two workshops about which we raise issues in this report offered in-depth discussions of regulations that pertain to billing for evaluation and management health care services and compliance with health care laws and regulations. During the course of discussions at those workshops, certain advice was provided that is inconsistent with guidance provided by the Department of Health and Human Services Office of Inspector General (OIG). Such advice could result in violations of both civil and criminal statutes. Specifically, certain consultants advocated not reporting or refunding overpayments received from insurance carriers after they were discovered. The consultants also encouraged the performance of tests and procedures that are not medically necessary to generate documentation in support of bills for evaluation and management services at a higher level of complexity than actually confronted during patients office visits. Furthermore, one consultant suggested that providers discourage patients with low-paying insurance plans, such as Medicaid, from using their services by limiting services provided to them and scheduling appointments for such patients at inconvenient times of the day.