OWCP Compliance – Billing Codes, Guidelines and Instructions
OWCP Compliance – How Should I Bill OWCP Healthcare Claims?
Expert OWCP Compliance Consultants and DOL Attorneys Are Available to Help Your Federal Workers Comp Clinic
Did You Know that Just 10 Incorrect OWCP Billing Claims to DOL Can Result in $ 100,000 and More in Liability? Business owners of federal workers compensation clinics know the problem. You want to do things according to the correct OWCP compliance guidelines, but no matter where you look you can’t get the OWCP guidance you need. Outside of some generic information on www.dol.gov and a four-minute time window you have to speak to an (uninformed) Department of Labor representative, all pertinent questions as to eligibility, pre-authorization, OWCP billing codes, how to make medical authorization requests, accepted conditions for a claim, and other critical clinical billing questions remain unanswered. Once you have become an accepted and enrolled provider, the government essentially ignores you—until your inexperience causes you to make OWCP billing mistakes!
OWCP and FECA Are Completely Different to All Other Medical Billing Routines
Department of Labor clinics are among the most complicated challenges in the entire healthcare industry. Contrary to common perception, the rules governing injured federal workers do not follow Medicare guidelines and also familiarity with commercial insurance payors does not really help to master the unique and sometimes esoteric Department of Labor and FECA claim billing regulations. Oberheiden P.C. offers claim auditing and billing services:
- Oberheiden P.C.: Former Department of Justice Prosecutors
- Oberheiden P.C.: Experienced DOL Healthcare Fraud Defense Attorneys
- Oberheiden P.C.: Lead Attorneys in Some of the Largest DOL Investigations in U.S. History
- Oberheiden P.C.: Expert DOL Billers and Compliance Consultants
- Oberheiden P.C.: Nationally Available DOL Advisors and DOL Defense Counsel
If you operate a workers’ compensation clinic and you don’t want to run into the FBI, go through intense subpoenas, recoupment and overpayment disputes, search warrants, or federal investigation—then do it right. Trust the experience of former DOJ Prosecutors in charge of Department of Labor cases and learn from lawyers and true expert consultants that have spent their entire careers in the workers compensation field.
Here Are Some of the Things that Might Go Wrong at Your DOL Clinic
In our work as former federal prosecutors with the Department of Justice overseeing U.S. Postal Inspection and Department of Labor healthcare fraud investigations as well as from our representations of federal workers compensation clinic owners across the United States, we typically run into one of the following problems that exposed medical providers, billing staff, and management to severe civil penalties—and sometimes even federal criminal charges.
- Wrong Code (Upcoding Through Modifiers, e.g. “Modifiers 25 or 59”)
- Wrong Code (Inappropriate Level of Care)
- Wrong Code (Routine High-Level Billing, e.g. for “Supplies 99070”)
- Billing for Two Mutually Exclusive Codes
- No or Delayed Discharges of Patients
- Low or Uncoordinated Return-to-Work Rate
- Incorrect and Inadequate Supervision (MD and PT)
- Incorrect and Inadequate Supervision (PT and Chiropractor)
- Incorrect and Inadequate Supervision (PT/OT and Massage Therapist)
- Poor and Inadequate Documentation (e.g. “Checkmark System”)
- Prescriptions of Controlled Substances (“Opioids”)
- Incorrect Integration of LPC and Psychologist
- Lack of Medical Necessity
Additionally, federal authorities are always suspicious when it comes to patient referrals. How do injured workers find the clinic? Who refers the patients to your clinic and is there any underlying financial arrangement? Who does the online marketing? Are the website disclaimers carefully reviewed and drafted? Are they HIPAA compliant?
- Illegal Kickbacks (Patient Referrals)
- Illegal Advertisement (Brochures)
- Illegal Advertisement (Online)
- Illegal Union Contacts
- Illegal Help Services to Patients
- Illegal Marketing (W2 or 1099 Compensation)
- Illegal Medical Directorship Agreement (Stark Law, Anti-Kickback)
- Lack of a Compliance Program
OWCP Billing Instructions – What Can Happen If We Bill Incorrectly?
These few examples, related to OWCP billing instructions and guidelines, and directly related to the federal False Claims Act, the Federal Employees’ Compensation Act (FECA), the Office of Workers’ Compensation Programs (OWCP) ECOMP Training Modules, the Anti-Kickback Statute, and federal Stark Law already demonstrate that federal workers compensation billing errors can trigger enormous penalties and sanctions. Increasingly, let’s be honest here, these consequences are criminal in nature. The U.S. Justice Department, the U.S. Postal Inspection Service, the Department of Health and Human Services (HHS), the Office of Inspector General (OIG), and the FBI have begun to systematically target federal workers’ compensation clinics by sending undercover agents to physician offices and physical therapy clinics, scrutinizing billing records for outliers, and by carefully examining affiliations between claims adjusters, union members, and business owners.
- Liability under the False Claims Act: $ 11,000 PER CLAIM SUBMITTED plus Penalties
- Liability under federal Healthcare Law 18 U.S.C. 1347: Up to 10 Years Imprisonment
- Liability under FECA: Program Exclusion
Don’t expose yourself to errors with OWCP billing codes and procedures. Mistakes happen even at the very best organized facility. Stop guessing, stop wondering, stop worrying! Call the former U.S. Department of Justice DOL prosecutors and experienced workers compensation attorneys of Oberheiden P.C. for a free and confidential consultation today!
How a Professional DOL Billing Company Can Help You
Every single time you submit a claim or attempt to submit a claim that is incorrect—whether you know it or not—you may violate the federal False Claims Act (FCA). The FCA does not require intent so any even accidental false claim’s submission may catapult you into federal enforcement jurisdiction. If you get caught, the government will almost always try to take you out of business because few clinics can actually survive the enormous penalties. Ten false DOL claims, for example, could quickly get you into the hundreds of thousands of dollars in liability.
- Shift Responsibility and Liability to Someone Else!
- Get Professional Advice and Do Things Right!
- Protect Your Reputation—Don’t Make Newspaper Headlines!
- Call Oberheiden P.C. Today for a Free Consultation!
As attorneys, we always recommend avoiding this potential exposure by referring your billing out to Department of Labor healthcare billing experts. The advantages for you are obvious: you don’t need to worry anymore whether or not your billing is correct. Further, if your billing turns out to be incorrect and you have an external billing service, you will typically be shielded from liability—that’s why you pay a service fee and that’s why the external billing company carries appropriate professional insurance.
Stop Worrying About Wrong OWCP Billing Codes: Get a Free Consultation from Oberheiden P.C.
DOL business owners and their billing staff must make difficult decisions each day. Oberheiden P.C. offers tested and proven support for federal workers compensation clinics and their staff, which covers OWCP billing codes, OWCP billing guidelines and OWCP billing instructions. Stop guessing, stop wondering, and stop worrying! Let us help you with HCFA 1500 and related documents.
What code do I use for new patients: 99201, 99202, 99203, 99204, or 99205? What are the requirements for the code I use? Is the code I use medically necessary? Is their appropriate documentation to justify the code I use? Am I at risk of upcoding? More specifically, what constitutes a problem focused, an expanded problem focused, a detailed, and what a comprehensive examination? How do I include past medical, family (hereditary diseases), social history (exercise, diet, relationships, work etc.) in the treatment plan and coding?
How does the analysis change for established patients? What happens if I routinely bill for high complexity and comprehensive exam and medical decision making? How many minutes are required to be spent with an established patient for these codes: 99211, 99212, 99213, 99214, 99215?
What risk levels do I need to pay attention to? Minimal Risk: one self-limited or minor problem, home ice therapy, elastic bandages, manipulations. Low Risk: two or more self-limited or minor problems, one stable chronic condition, acute uncomplicated injury, plain film X-rays, OTC medications, therapy, and manipulations. Moderate Risk: one or more chronic conditions with acute exacerbations, two or more stable chronic conditions, undiagnosed new problem, physiologic tests without stress, plain film x-rays, MRI/CT, manipulations, therapy, medical co-management, fracture or dislocation—or High Risk?
Excerpts of a Federal Workers Compensation Billing Agreement
WHEREAS, Vendor provides medical billing and collection services (“Services”) to Client for the fees described herein; and
WHEREAS, Client provides healthcare services to patients (“Patients”) that results in healthcare claims and accounts receivable and the need for billing and collection services; and
WHEREAS, Client desires to contract for such healthcare billing and collection services from Vendor and Vendor desires to provide such healthcare billing and collection services as described, each under the terms and conditions described herein.
NOW, THEREFORE, in consideration of the foregoing recitals and the terms, conditions, and other provisions herein, and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the Parties hereto, intending to be legally bound, hereby agree as follows:
Article I: Services
A. VENDOR Services. Client hereby engages and authorizes and appoints to provide the Services and perform other actions related thereto, as explicitly described and set forth in Exhibit A hereto. Vendor is hereby designated and appointed as Client’s agent and attorney-in-fact to: (i) bill in Client’s name and on Client’s behalf; and, (ii) collect on Client’s behalf fees for services rendered by Client from Payors. Vendor will process all of the Client’s insurance claims for payment by Government Sponsored Programs (collectively, “Payor(s)”). A Government Sponsored Program includes, but is not limited to, Department of Labor Workers’ Compensation or any other applicable (partially or fully, directly or indirectly) government funded healthcare program, including such programs when they are secondary to another payor.
Article IV: Legal Compliance
A. Legal Compliance by Client. Client certifies that he, she or it shall always act in accordance with any and all applicable laws, rules, guidelines and requirements of governmental, accrediting, reimbursement, payment and other agencies having jurisdiction over Client’s operations, including without limitation, compliance with the following requirements: (a) Client has complied in all material respects with, is in material compliance with and shall remain in material compliance with, all applicable laws and regulations of foreign, federal, state and local governments and all agencies thereof relating to Healthcare Laws and Practices (as defined below). Client has not received notification of or been under investigation with respect to, any violation of any provision of any federal, state or local law or administrative regulation, or of any rule, regulation or requirement of any licensing body relating to Healthcare Laws and Practices. For purposes of this Agreement, “Healthcare Laws and Practices” means all federal, state or local laws, rules, regulations or guidelines regarding (i) any government-sponsored healthcare program, including Medicare and other federally or state funded entitlement programs, and including those laws, rules, regulations and guidelines related to covered services, charging practices, billing, collection, marketing and advertising, (ii) kickbacks, fee-splitting and other referral practices, including, without limitation, the federal anti-kickback statute set forth at 42 U.S.C. Section 1320a-7b (the “anti-kickback statute”), the federal Client self-referral law set forth at 42 U.S.C. Section 1395nn (the “Stark law”), and other related or similar laws and regulations, (iii) the federal False Claims Act, 31 U.S.C. 3729 et seq.; (iv) the federal Civil Monetary Penalties Law, 42 U.S.C. 1320a-7a; (v) the federal Exclusion Authority Statute, 42 U.S.C. 1320a-7; (vi) the federal Physician Sunshine Act, 42 U.S.C. 1320a-7h and its implementing regulations; (vii) the Federal Food, Drug and Cosmetic Act, 21 U.S.C. section 301 et seq., together with any rules and regulations or national Laws promulgated thereunder; (viii) the Health Insurance Portability and Accountability Act of 1996, as amended by the Health Information Technology for Economic and Clinical Health Act of 2009, 42 U.S.C. Section 201 et seq., and any other laws governing the privacy, security and confidentiality of healthcare information (See, Exhibit B); and, (ix) the Travel Act, 18 U.S.C. 1952; (b) Client and Client’s agents, employees, independent contractors, or staff (“Agent(s)) have not and shall not engage in any conduct that violates any Healthcare Laws and Practices.
Call Attorney Dr. Nick Oberheiden Today and Get a Free and Confidential Consultation!
We represent clients in need of qui tam defense, involved in False Claim Act investigation, facing federal criminal charges, and in other legal matters.
Dr. Nick Oberheiden, founder of Oberheiden P.C., focuses his litigation practice on white-collar criminal defense, government investigations, SEC & FCPA enforcement, and commercial litigation.