You’re with a patient. More are in the waiting room. There’s a commotion. Men in uniform sweep into your office and a guy in a suit brandishes official looking paperwork in your face. As they execute their search warrant, they take photographs, your computer, and some patient files. Then they leave you in a state of shock.

Think I created the above scenario to get your attention? Sorry to disappoint you. Over the past few years, scenarios like this are becoming more common. And you won’t see your colleagues blog about it either. Once they’re caught in the spotlight, it’s all they can do to catch a breath. 

It could have been local law enforcement, but it’s more likely state or federal. For instance: DHHS/OIG, better known as the Department of Health and Human Services, Office of the Inspector General.

I know what you’re thinking. This goes way beyond an audit. These doctors must have done some pretty brazen things to merit a search warrant! I’d never do anything like that. Criminal? Fraud? Not possible!

Guess again. It’s easier than you think. One of the simplest ways to head down the path ultimately labeled  “fraud” is your CPT codes. What problem could possibly result from your codes? Imagine that a CPT code you use regularly isn’t getting reimbursed. You’re buddy, Bob, let’s you know that he’s having better luck with a different code. Or perhaps your management consultant provides something better. The alternate doesn’t seem too different, so you switch. Later, this becomes part of your defense argument as you protest your innocence during talks over a two year period with the investigators sifting through your data.

Let’s look at an example. Suppose that 5 years ago you began using 97012 as part of your office visit to account for extended time with the patient. Today, you wonder why the investigators photograph your office as part of their intrusion. And later you learn they’re looking for mechanical traction equipment – which you don’t own. You tell your attorney that every chiropractor you know locally is using that code.

Full story