Reporting Cases of Lab Billing Fraud to the Office of the Inspector General (OIG)

Joe Plandowski co-founded In-Office Pathology in 2005. Over the past six years, IOP has helped to launch and manage 50 histology labs for urology, gastroenterology, and dermatology practices. I quoted him extensively about in-office-labs in a recent note summarizing key points from a teleconference he delivered (see: Pathologists Who Staff In-Office Labs: Who Are They and What Motivates Them?) In this presentation, he made mention of reporting Medicare billing fraud to the OIG of HHS. I asked him to write a guest blog specifically on this topic, which is presented below.  --Bruce Friedman

I made a presentation at a recent national meeting and also during a recent teleconference in which I stated I had reported several issues to the Office of Inspector General (OIG) and encouraged others to do the same. That comment brought forth other questions which are addressed here. For the record, reports can be filed at the Office of Inspector General, Department of Health & Human Services, 330 Independence Avenue SW, Washington, DC 20201.

What can be reported? As far as I am concerned, anything I see that is well outside the laws and regulations or good laboratory practices, as I know them, is reported. That includes for example: overutilization, underutilization, falsification, and inducement. In my business, we play by the rules and expect everyone else to play by those rules. As a taxpayer I have no interest in others ripping off my tax dollars. Furthermore, as a Medicare recipient my sensitivity to any scams of the Medicare program is heightened. When I see it, I report it, and encourage others to do the same. I want a level playing field. 

What are the consequences of such reporting? For one, you have to write a letter explaining what you saw in as much detail as possible. I do provide my name, address and phone number and a statement that this is not a whistleblower's action nor is any compensation being sought. For another, you may have to devote some time to meeting with CMS field agents and FBI agents to provide further details. We have had those visits. They are not stressful meetings. You are not accused of anything. They are just trying to get all the facts straight. 

Some examples of what has been reported may be helpful.

• A pathologist-owned laboratory was doing a reverse TC/PC ⁽¹⁾ arrangement with a urology group. A questionable cytology procedure was performed on all prostate biopsies as a result of that arrangement which significantly inflated the overall bill to the patient and/or the patient's insurer.
• A pathologist was working in at least two different laboratories reading a very high number of total cases per year. One of the laboratories was a high volume in-office pathology laboratory at a urology practice. Incredibly, no special stains or IHC stains were ever ordered on any of the tissues at the in-office urology laboratory.
• A laboratory was built and registered with CLIA to function as an in-office pathology laboratory serving urology patients. Although registered as a physician's office laboratory, it functioned as a commercial laboratory bringing in specimens from out-of-town urology practices.
• A pathologist offered to manage the building of an in-office pathology laboratory for a group of gastroenterologists at a minimal fee in exchange for a long term professional pathology services agreement. It would take my company about 1,000 man-hours of work to do that project and that is the company's core competence. Medicare's reasonable compensation equivalent (RCE) is about $100 per hour for a pathologist. To avoid inducement, the pathologist should have charged at least $100,000 for that project instead of less than 25% of that amount.

I do not go around looking for things to report. But when you are in the business of providing laboratories to specialty practices across the country, you run into all sorts of arrangements between specialty practices and pathologists, commercial laboratories, and others. Providers of professional and technical pathology services to specialty practices that send out their patients' specimens for diagnosis do not wish to lose that work to a decision by the specialty practice to build its own in-office pathology laboratory. As a result all sorts of schemes are created, some of which are outside the boundaries of what is allowed. Pathologists complain about overutilization at in-office pathology laboratories. Rather than complain, report it. When I see things outside the allowed boundaries I report it. So should everyone else. It's the easiest way to clean up fraud or bad medicine in the healthcare field. The sooner the better.

⁽¹⁾ Reverse TC/PC. Tissues are processed in the dermatologist’s in-office laboratory but sent out for diagnosis (technical component; TC) with professional component (PC) billing by a pathologist. The dermatologist bills the TC of $70 and the pathologist bills the PC of $36.