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Advocating for people with intellectual, developmental, and other disabilities to lead full and equitable lives.
AHRC New York City

Advocating for people with intellectual, developmental, and other disabilities to lead full and equitable lives.

Section 4.09: Billing Third Party Payers

Section: 4.09
Issued: 12.31.2005
Updated: 03.20.2023

Purpose

The purpose of this policy is to provide guidance related to billing of third party payers.

Policy Overview

AHRC NYC will bill third party payers accurately for all services appropriately provided to people it supports.

Scope

This policy applies to all employees of AHRC NYC, particularly those who provide services and prepare documentation for the submission of claims and those who prepare claims to be submitted to third party payers.

Procedure

AHRC NYC employees and independent contractors will provide only those services that are necessary and will submit only true and accurate bills to third party payers that reflect accurately the services provided and that are not fraudulent. No employee or independent contractor may knowingly present or cause to be presented a claim for payment that is false, misleading or fraudulent.

Examples of fraudulent billing practices that the New York Medicaid program has identified include:

  • Billing for services that were not provided (e.g., a speech therapy session was not held);
  • Duplicate billing which occurs when a provider bills Medicaid and also bills private insurance and/or the recipient;
  • Requiring the recipient to return to the AHRC NYC office for more visits when another appointment is not necessary;
  • Providing unnecessary services and billing a third party payer for the unnecessary service;
  • Upcoding (e.g., billing for an evaluation when only a routine visit occurred, billing a full unit of service when, based on the duration of the service time, only a half unit should be billed).
  • Having an unlicensed person perform services that only a licensed professional should render, and bill as if the professional provided the service;
  • Billing for more time than actually provided (e.g., a longer counseling session); and
  • Billing for an in-home service when there was none.

Claim submissions must be conducted in accordance with the requirements of the applicable payer (e.g., Medicaid, OPWDD, State Education Department), including but not limited to those related to coding, bad debt reporting, medical necessity, credit balances and duplicate billing.

Employees who create and submit bills to third party payers will be adequately trained to do so and will have the necessary skills to perform the job.

Inaccurate claims submission may subject AHRC NYC, involved employees and other representatives to civil or criminal penalties. Any employee or other person who presents or otherwise is involved in the submission of a false, fraudulent or fictitious claim for payment may be subject to immediate termination.

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