61 Billing Errors In Seven Years

Audit of the 61 Billing Errors The Government produced evidence of 30 errors that are 96 units billed at $480, and 31 errors that are 96 units billed at $240. We can not determine how each and every one of these 61 billing errors occurred simply because we don't have access to all of Clinic's records, but we can isolate some specific causes. 1. Incorrect Tick Sheets Even though the Tick Sheet is clear and unambiguous, billing errors would occur if the Medical Assistant or the Doctor put down the wrong information. We do not have Tick Sheets for every incorrect billing to Medicaid, but of the ones we do have, three are incorrectly completed and resulted in overpayments by Medicaid for the 95004 procedure: D60 Tick Sheet for Michael Z., 2-15-00, 96 units marked G10B Tick Sheet for Jatyn T., 12-20-00, 96 units marked Tick Sheet for Nathan L., 12-28-01, 96 units marked These errors resulted in 96/$480 billings, i.e., 96 units @ $480 Charge. According to Mona Spears’ testimony, the Tick Sheet for Jatyn T. was completed by Dr. Cole, who stood in for Dr. Rana while he was in Pakistan on an extended visit. We don’t know who completed the other two, whether it was Dr. Rana or the Medical Assistant, as the Tick Sheets only have items circled or checked, no handwriting. The Receptionist would have innocently perpetuated these errors. Once made, they were almost impossible to catch, simply because 96 and $480 belong together, it is what the Office Manager would expect to see because the majority of patients at the Odessa Allergy Clinic did in fact receive 96 units and were charged $480. Unless the Office Manager personally knew the patient was under two years of age, or was scrutinizing the dates of birth on the Claim forms, she would likely never catch these errors. 2. Receptionist fixated on the Charge instead of the Units Every time the Receptionist typed in the 95004 procedure code, she was prompted to type in the number of tests given. There was no 96 default, the Receptionist had to intentionally type in 96 or 48. The very first error demonstrates that the Receptionist did not understand how Medicaid paid for the 95004 procedure. The patient, Marco P., was billed for 96 Units @ $5.00 on 5-11-98. $5.00 is the charge for one unit. To make this error, the Receptionist first keyed 95004 for the Procedure Code, then 96 for the Units. When Medical Manager displayed $480 in the Charge field, the Receptionist had to override the $480 by typing in $5. This took a deliberate action. Then, on 5-19-98, the Receptionist [we assume] billed again for the 95004 procedure, and typed in 96 units. This time she overrode the $480 Charge by typing in $475. She obviously thought she was correcting the billing by making the total for the 95004 procedure come up to $480. But, instead of correcting the billing, she was double billing, because Medicaid pays by Units, not by Charge.

In another instance, for Aaron M., the Receptionist billed twice for the 95004 procedure: 12-3-98 for 96 units @ $80 and 12-7-98 for 96 units @ $400. Again, this is an obvious effort to make the total charges come up to $480. Again, instead of correcting the billing, she caused a double billing. All 31 of the 96/$240 errors are a fixation on the $240 charge. The Receptionist typed in 95004 for the Procedure, typed in 96 Units, and then deliberately changed the $480 charge to $240. The reasonable conclusion is that she thought she was billing correctly because the Charge was correct, when in fact she was causing an overpayment. Because this action is so deliberate, and these errors are interspersed among correct entries, an audit trail would most likely link these all to the same Receptionist. The Jury heard nothing from Defense Counsel about this mistaken fixation on the Charges instead of the Units. And yet it explains over half of the errors. 3. Simple human error Medicaid, in its Provider Agreement, acknowledges that some human error is inevitable. Section 1.3.6 states: "Provider must refund any overpayments, duplicate payments, and erroneous payments which are paid to Provider by Medicaid or a third party as soon as the error is discovered." At least one of the 96/480 errors is directly traced to simple human error on the part of the Receptionist. Liset Sotelo admitted in her testimony that for patient Briton C., DOS 10-14-02, she keyed 96, even though the Tick Sheet indicated 48 units. Undoubtedly other billing errors were in this category -- simple human error. The literature on data entry error rates suggests that a .1% to 2% error rate is acceptable. If we look at 61 billing errors for 200 patients, we see a 30.5% error rate. That is exactly the kind of distortion the Government wanted. However, if we take the errors as a percentage of all Medicaid procedures, the error rate is .35%. More

Defense Counsel failed to provide the Jury with information on the total number of Medicaid patients seen each month by the Clinic and the total number of procedures performed, or to provide an expert to explain the acceptable error rate to the Jury. 4. Gross carelessness Some of the billing errors are traced to gross carelessness. Joseph T.’s Patient Financial History record shows that on September 8, 2000, he was billed 3 times for the 95004 procedure and 4 times for the initial office visit procedure. The 95004 billings are: 48 units @ $240, 48 units @ $240, 96 units @ $480. The Medicaid Claim form included two billings for 96 units @ $240 for the same date of service, and Medicaid paid both claims at the same time. These errors could not have escaped the Office Manager's attention. Elodia Martinez was Office Manager at the time. Defense Counsel did not question her about this account. She was not asked if she knew about these billing errors. She was not asked why she did not initiate a refund to Medicaid. She was not asked

if she called this to Dr. Rana's attention. The Jury heard nothing about this gross carelessness from the Defense Counsel. Correcting the Errors The 96/$480 errors, once committed, would have been very difficult to catch, even by the most conscientious Office Manager. This is simply because 96 units and $480 go together, and the majority of patients received 96 units. Unless the Office Manager was paying particular attention to the Date of Birth, and calculating age at date of service, these errors would not be caught. There simply wasn't anything on the billing summary, or the Claim Forms or the Remittance and Status Report, to red flag these billings as errors. The 96/$240 errors are an entirely different matter. Unlike the 96/$480 errors, these errors should have been very easy for the Office Manager to catch. 96 and $240 just do not go together, and that should have been a red flag to the Office Manager. In addition, these billings produced a payment of $240 for the 95004 procedure, which was not what the Office Manager would expect. For the period 1997-1999, the payment for 96 units was $258.24 and 48 units was $129.12. For 2000-2002, the payments went up slightly, to $262.08 for 96 and $131.04 for 48. So a payment of $240 for the 95004 procedure would have been very irregular. In fact, all 31 of these errors were caught and partially corrected. We know they were corrected because the Patient Financial History ledger sheets show 48 units @ $240, not the 96 units @ $240 that was billed to Medicaid. This is what the Defense Counsel referred to as the software glitch, the Receptionist typing in 48 units and Medical Manager spitting out 96 units on the Medicaid Claim. In truth, the discrepancy between the ledger sheets and the Medicaid claims is easily explained by the Medical Manager data flowchart. When these errors were corrected and how they were corrected gives us good evidence that the Office Manager is the person making the corrections and that she knew Medicaid overpayments had been made and did nothing to issue refunds. We have 5 instances of the billing error being corrected after the original claim for 96/$240 was submitted, and then a corrected claim for 48/$240 was submitted. 48. Emanuel S. DOS 1-24-00. Two claims were submitted for this patient. The first was for 96/$240 and the second, corrected claim, was for 48/$240. The claim was denied by Medicaid on 1-21-01 for being past filing deadline. No refund was necessary for this patient because Medicaid did not pay the claim. 65. Jaime L. DOS 5-2-00. Four claims were submitted for this patient. The first was for 96/$240, which was not paid. Then the patient's account was corrected to 48/$240, and a second claim submitted. A third and fourth claim, both for 48/$240 were submitted before the Claim was denied on 8-28-01 because it was past the filing deadline. No refund was necessary for this patient because Medicaid didn't pay the claim. 75. Joseph T. DOS 9-8-00. Three claims were submitted for this patient. The first two were for 96/$240, and the third, corrected claim, was for 48/$240. Both of the

first two claims were paid by Medicaid, but the third was not paid. The overpayment on this account was $348.96, but the Office Manager did not issue a refund to Medicaid. 87. Michael G. DOS 2-19-01. Two claims submitted for this patient. The first one was for 96/$240, and the second, corrected claim, was for 48/$240. In this instance, only the corrected claim was paid by Medicaid, so no refund was necessary. 119. Tyra S. DOS 11-20-01. Two claims were submitted for this patient. The first was for 96/$240, and the second, corrected claim, was for 48/$240. Both claims were paid by Medicaid. The Office Manager should have issued a refund to Medicaid for $240, but did not do so. If Dr. Rana were perpetrating a fraud scheme, it is unlikely he would be correcting these claims, as that would be counter-productive. Nor would he be correcting them if, as portrayed by all the Clinic employees that testified, he didn't know anything about how this software worked and didn't even know his own password. He simply wouldn't know how to make the corrections. The Office Manager is the only person who would have submitted corrected claims for these five accounts--the Receptionist would not have done so. Correcting these five accounts required a very deliberate action. The data flow chart shows how Medical Manager processes and stores data. It shows that after the Receptionist enters the Procedure data into the Patient's Activity Record, Medical Manager stores it in the Open Items File. When the Daily Close is completed, a stripped down version of the data is copied to the Patient's Procedure History file. Thereafter, Medical Manager makes no attempt to keep the Open Items file and the Procedure History file in sync. To print a corrected claim to submit to Medicaid, the Office Manager had to change the data from 96 units to 48 units in the Open Items file. To correct the Patient Financial History, the Office Manager had to change the data from 96 units to 48 units in the Patient's Procedure History file. Two files to change. Changing one would not change the other. For the remaining 96/$240 errors, we assume they were corrected at the time the payment was posted to the account, when it was too late to file a corrected claim. All of them, except one, resulted in a payment of $240, which should have been a red flag to the Office Manager when she posted the payment. All of them resulted in an overpayment by Medicaid, but no refunds were issued by the Office Manager. The Office Manager at the time, Elodia Martinez, was never asked by Defense Counsel if she noticed these overpayments. She was never asked by Defense Counsel why she didn't initiate refunds to Medicaid? She was never asked by Defense Counsel if she told Dr. Rana about these billing errors. What Mr. Goldstein insisted on calling a software glitch was in fact a combination of deliberate actions on the part of Dr. Rana’s staff:

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A Receptionist who deliberately keyed 96 units and deliberately changed the $480 Charge to $240 An Office Manager who caught every one of these mistakes, and in some instances submitted corrected Claims, but did not bother to refund Medicaid for the overpayments

Mr. Roomberg argued, in his Closing Arguments, "The staff didn't know what was going on. That is why they're not charged with aiding and abetting. They helped him unknowingly." The truth is, in the initial stages of this case, the Government let it be known that all employees of the Odessa Allergy Clinic were under the umbrella of suspicion. The fear of being prosecuted as an accomplice would have discouraged any of them from admitting their own mistakes. The truth is, the Office Manager knew about every one of these 96/$240 errors. Elodia Ruiz-Martinez was the Office Manager for most of this time period, including when the 5 corrected claims were submitted to Medicaid. On July 21, 2003, she swore in a affidavit that Dr. Rana "never advised, suggested, asked or told me or anybody else in his office to ever bill, collect, or charge any patient incorrectly or falsely, or without rendering services, in any way, method or manner." She testified at Dr. Rana's trial, called by the Government. She gave no indication that she even knew about these billing errors, or that she ever told Dr. Rana about them -because she was not asked. Even though Martinez specifically said that as Office Manager she is the one who received the payments and posted them to the accounts, Defense Counsel never asked her if she knew about these overpayments.