Workers’ Compensation Consultants for DOL Billing Compliance

Compliance with Office of Workers Compensation Program (OWCP) and other U.S. Department of Labor (DOL) program guidelines presents unique challenges for health care providers. Our federal workers’ compensation consultants help clinics, physicians, and other providers nationwide develop and implement comprehensive and custom-tailored DOL billing compliance programs. 

Billing the U.S. Department of Labor (DOL) under a federal workers’ compensation program is unlike billing Medicare, Medicaid, or a private workers’ compensation insurer. There are unique restrictions on the services that are eligible for reimbursement, unique rules for choosing the correct billing code, and unique requirements for supervising ancillary service providers. Yet, all health care providers that bill the DOL are expected to strictly comply with all applicable laws, rules, and regulations. For most providers, hiring an experienced federal workers’ comp consultant is the only practical option for avoiding the severe penalties for DOL billing fraud.

At Oberheiden P.C., our lawyers and consultants help health care providers comply with all requirements under Office of Workers Compensation Program (OWCP) and other DOL workers’ compensation benefit programs. We help providers implement programs that allow them to efficiently comply with the complex billing requirements under these programs and all other applicable workman’s comp laws, rules, and regulations. We develop compliance programs that are specifically designed to protect providers during DOL workers’ comp audits and that will withstand scrutiny in the event of a federal health care fraud investigation. 

5 Key Components of Federal Workers’ Compensation Compliance

Are you using physical therapy codes that conflict with other modalities of treatment? Are you generating and storing adequate documentation to substantiate the evaluations for which you are billing the DOL? Could you be at risk for health care fraud allegations due to failure to adequately supervise a chiropractor or other ancillary service provider? Are you prepared to respond appropriately in the event that one of your employees or your third-party billing administrator makes a DOL billing mistake? For many health care providers, the answer to these questions is, “I don’t know.” 

Our federal workers’ compensation consultants can help you answer these questions with confidence. With a team that includes former federal health care fraud prosecutors, nationally-recognized health care fraud defense lawyers, compliance auditors and consultants, and federal workers’ compensation experts, we bring certainty to the process of billing the DOL. 

Put our highly experienced team on your side

Dr. Nick Oberheiden
Dr. Nick Oberheiden

Attorney-at-Law & Founder

Amanda Marshall
Amanda Marshall

Former U.S. Attorney

Local Counsel

Lynette S. Byrd
Lynette S. Byrd

Former Federal Prosecutor

Partner

Aaron L. Wiley
Aaron L. Wiley

Former Federal Prosecutor

Local Counsel

Subodh Chandra
Subodh Chandra

Former Federal Prosecutor

Local Counsel

Elizabeth K. Stepp
Elizabeth K. Stepp

Partner

Roger Bach
Roger Bach
(Non-Lawyer)

Former Special Agent, OIG

Dennis A. Wichern
Dennis A. Wichern
(Non-Lawyer)

Former Special Agent-in-Charge

Chris Quick
Chris Quick
(Non-Lawyer)

Former Special Agent, FBI

Kevin M. Sheridan
Kevin M. Sheridan
(Non-Lawyer)

Retired Supervisory Special Agent, FBI

Ray Yuen
Ray Yuen
(Non-Lawyer)

Former Supervisory Special Agent, FBI

Gamal Abdel-Hafiz
Gamal Abdel-Hafiz
(Non-Lawyer)

Former Supervisory Special Agent, FBI

1. Correct Use of Medical CPT Codes

Coding violations are among the most-common factors that trigger federal workers’ comp audits and health care fraud investigations. There are numerous factors that should influence the selection of CPT codes, from the appropriate “Levels” and “Modifiers” to the patient’s treatment history and potential future treatment needs. These factors are, of course, in addition to the nature of the medical service itself that is being billed. 

New Patients vs. Returning Patients

Under the Federal Employees’ Compensation Program and other OWCP programs, health care providers are required to bill differently for new and returning patients. While the billing rules are generally stricter for returning patients (for whom, generally, time limitations are more restrictive), there are potential stumbling blocks with regard to billing the DOL for new patients as well. For example, an initial outpatient exam can be billed with CPT code 99203 or CPT code 99204. The latter offers a higher reimbursement rate (for 45-minute, rather than 30-minute, evaluations), but both can be used for patients who present job-related injuries of “moderate” severity. As a result, the DOL will often heavily scrutinize providers who consistently submit CPT code 99204 rather than CPT code 99203.

With returning patients, one of the most-common allegations against federal workers’ compensation health care providers is overbilling (or “upcoding”) through the selection of an improper CPT code. For example, CPT codes 99213, 99214, and 99215 all cover evaluation and management for return visits, but with varying consultation times of 15, 25, and 40 minutes, respectively. 

Physical Therapy vs. Other Modalities

CPT codes for physical therapy will often conflict with the billing codes for other treatment modalities. As a result, once a provider submits a physical therapy CPT code to the DOL, billing for certain other types of treatment will become prohibited, and submitting a prohibited code will raise an immediate red flag. We call this the DOL “Coding Trap.” Overutilization of physical therapy codes is a common issue in DOL workers’ comp audits and investigations as well, with DOL personnel often paying particular attention to the use of CPT codes including (but not limited to):

  • 97140
  • 97760
  • 97530
  • 97110
  • 97112
  • 97035
  • 97113
  • 97116
  • 97124

CPT vs. NCCI

Many health care providers that bill DOL programs have questions about the applicability of various types of billing and workers’ comp codes, including CPT and NCCI. CPT stands for “current procedural terminology,” and CPT codes are supposed to offer providers “a uniform process for coding medical services that streamlines reporting and increases accuracy and efficiency.” NCCI is the acronym for the National Council on Compensation Insurance, and NCCI codes are used to classify employees for purposes of establishing the rates for workers’ compensation coverage. While CPT codes are far more relevant to health care providers billing under DOL programs, having an understanding of NCCI codes is important to avoid allegations of being complicit in a conspiracy to improperly bill for services rendered. 

2. Workers’ Compensation Program Billing Administration

Once you have a thorough understanding of the proper use of CPT billing codes within the context of your federal workers’ compensation health care practice, the next step is to develop and implement compliant billing administration policies and procedures. This involves developing customized compliance documentation that addresses the unique aspects of your business or practice, and then implementing your newly-developed compliance program through dissemination, training, and enforcement. Our health care lawyers and federal workers’ comp consultants routinely assist clinics and other providers with the development and implementation of DOL compliance programs, and we can work with you to establish billing administration protocols that help ensure that you will not be at risk for federal charges in the event of a workers’ comp audit or Office of Inspector General (OIG) investigation. 

3. Contracts with Ancillary Service Providers 

As a result of reductions in reimbursement rates for providers under DOL workers’ compensation programs, many providers have sought to capitalize on their referrals to ancillary service providers. While there are lawful ways to structure financial relationships with third-parties, providers that bill the DOL must be extremely cautious to avoid exposing themselves to prosecution under the Stark Law and the Anti-Kickback Statute. These federal laws prohibit the payment of compensation based upon the referral of federally-funded patients, and relationships with chiropractors, acupuncturists, physicians, toxicology laboratories, pharmacies, durable medical equipment (DME) companies, rehabilitation facilities, and other providers are all subject to heavy scrutiny by the DOL. 

Even if a compensation arrangement with an ancillary service provider is legally-compliant, failure to adequately document the arrangement’s legality can create problems in the event of a workers’ comp audit or OIG investigation. As a result, prior to entering into financial relationships with ancillary service providers, providers that bill the DOL must enter into contracts that are written specifically to avoid Stark Law and Anti-Kickback Statute implications. 

4. Contracts with Billing Administrators, Marketers, and Other Third Parties

In addition to relationships with ancillary service providers, relationships with billing administrators, marketers, and other third parties can also expose health care providers to civil and criminal penalties for DOL fraud. This exposure can come not only from structuring compensation arrangements that violate the Anti-Kickback Statute or Stark Law, but also from misplacing trust in these unrelated entities. Two examples of common issues leading to DOL fraud conspiracy allegations and other federal charges include:

  • Billing errors made by third-party billing administrators (as the health care provider, the DOL will prosecute you regardless of whether you hired a third party to manage your program billings); and,
  • Unlawful collection and sale of patient information by marketing and “lead generation” companies (as a health care provider, you can be prosecuted for buying leads even if you were unaware that the information you purchased was unlawfully obtained).

5. Internal Audits and Event Response

Finally, in addition to developing and implementing comprehensive compliance programs, the DOL expects program-participating health care providers to monitor personnel compliance and enforce their policies and procedures as well. This means conducting internal compliance audits and having a plan of action that can be executed in the event of an actual or potential violation. Beyond DOL-specific issues, a comprehensive compliance program must also address issues such as employee discipline and enforcement of third parties’ contractual obligations. With our federal health care lawyers’ and workers’ compensation consultants’ extensive experience in all DOL compliance and enforcement matters, we help providers develop, implement, and enforce policies and procedures so that they are not at risk when the DOL comes calling. 

Speak with a Federal Workers’ Compensation Consultant at Oberheiden, P.C.

Are you concerned about the adequacy of your clinic’s or practice’s DOL compliance program? Do you need help addressing a compliance deficiency or violation? If so, we encourage you to get in touch. To speak with a member of our federal workers’ compensation fraud consulting and defense team for free, call (214) 692-2171 or inquire online now.

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