A Warning from Wayne van Halem

Posted on in Billing/Reimbursement

By Wayne van Halem, President, The van Halem Group

We’ve received word from several VGM members who have been contacted by a company out of the Philippines trying to engage companies in paying for referrals on back braces. The entity makes claims that their "surrogate agreement" is alright with CMS. This is a very strong warning to any suppliers who consider engaging with this company and any others that make similar claims.

This Philippines company indicates it will provide the lead, orders, medical records, etc. All you have to do is submit the claim to the government for payment, which ironically, is where the potential for a false claim violation or improper payment occurs. They have no liability in the process and leave you holding the bag.

Often times, what this company promises is too good to be true. I understand with the reimbursement cuts that many are looking for opportunities to generate more revenue. While there is generally nothing wrong with lead-generation services and direct-to-beneficiary marketing, some of these companies are engaging in suspect activity including cold-calling, misleading and confusing marketing, and even, in some cases, actually paying the physician to perform a telephone consultation with a patient and order orthotic bracing. I even recently received a call on my cell phone from someone indicating that they were returning my call following my request for a back brace from Medicare. This was absolutely a cold-call – which is prohibited for Medicare patients. How they got my number as being associated with a Medicare patient is another story.

This is No Joke

The important thing to remember here is that you cannot contract with another entity to do what you are not allowed to do yourself. If you pay the lead generation service for the referral and they pay the physician for the evaluation, then you, yourself, have unwittingly paid for the referral. As you know, that is violation of the Anti-kickback Statute, which carries criminal penalties of up to five years in prison, criminal fines up to $25,000 per violation, and civil monetary penalties of up to $50,000 per violation. This is no joke. See the process outlined below.

Strip all of the steps away in this scenario, and you may have violated the Anti-Kickback Statute. Also, because physicians do not have any established relationships with the patients and often times are located nowhere near the patient, it’s very easily detectable in your claim data.

Another thing to note is many of these companies will make claims that an attorney or consultant has reviewed and approved their process. If so, get the name and number of who they say has, contact that person, and ask for evidence of such in writing. You’ll likely find that such a review hasn’t occurred.

Codes are Heavily Targeted

These codes are being heavily targeted, and rightfully so, by auditors and ZPIC investigators. Entering into an arrangement like this and dramatically increasing your billing in this product category will quickly put a target on your back that could lead to increased audits, denials, extrapolated overpayments, payment suspensions, or revocations. We have seen good suppliers get caught up in this mess, and the entities they engaged with have no liability as they have not submitted any claims to the government.

Don’t get caught up in this. Heed this warning. If you engage a lead-generation service, conduct your due diligence on their processes, engage your own counsel to review all contracts and marketing materials, and perform regular evaluation of their telephone calls and procedures. Make sure you scrutinize the referrals and understand where they came from. A legitimate lead-generation service should have no problem providing this information.

If you have questions or have more information about these companies calling you that you’d like to share, please call The van Halem Group at (404) 343-1815.