Medicare audit challenges with Mohamed Rifai

Dan King [0:00]I am delighted today to be joined by Dr. Muhamad Rifai, the founder of Blue [0:08]Introduction to Dr. Mohamed Rifai Dan King [0:06]Mountain Psychiatry and a psychiatrist. Muhamad, welcome to the show. It's good to have you. Dr. Muhamad Rifai [0:12]Thank you for hosting me on your show. It's a pleasure to talk to your audience. Dan King [0:17]So Muhamad, we'd love to start with just the basics on Blue Mountain Psychiatry. Can you tell us how old it is, roughly how many clinicians are involved in the basic services that you offer? Sure, sure. Dr. Muhamad Rifai [0:27]I am, by training, I'm an internist and a psychiatrist. I trained at the University of Virginia. I'm board certified in internal medicine, psychiatry, and addiction medicine. And I worked at the National Institute of Mental Health after my residency, and then moved to Pennsylvania to work for a local hospital for a few years prior to starting Blue Mountain Psychiatry. Blue Mountain Psychiatry has been around for about 15 years. And it's a group practice that has three offices. We are in the greater Lehigh Valley area, which is about an hour from New York City. We're an hour west of New York City. We're an hour northwest of Philadelphia. It's a greater metropolitan area, multiple smaller city of a population of about a million. And we serve basically that population. Started Blue Mountain Psychiatry in 2011. Basically, we've been going on strong. Since then, we expanded significantly. We have three offices. We still have three offices. And at the height of our progress, I had about 35 employees. And we're down now to about 12, 13 employees and we're still going strong and [1:48]The Journey of Telehealth Adoption Dr. Muhamad Rifai [1:45]we're getting ready to bounce back. Dan King [1:48]And what are you bouncing back from? Dr. Muhamad Rifai [1:50]So I am an early adopter. So in 2006, I started doing telehealth work when that wasn't popular. I basically started a emergency telehealth program for the local hospital in my area. And nobody was doing telehealth at this time. I basically, by 2020, when COVID hit, I had about 20,000, 25,000 hours of telehealth experience, which I gladly provided to fellow colleagues and other psychiatrists and health systems around the area. Dr. Muhamad Rifai [2:26]But basically, I started a telehealth program. Medicare asked for our help in providing telehealth program to rural nursing homes in Pennsylvania. And unfortunately, in 2017, because of the lack of understanding of new services, my practice came under the watchful eyes of the federal government and the United States Department of Justice. They initiated an investigation questioning the validity of our services, specifically psychiatric encounters and psychotherapy services that we provided [3:03]Facing Allegations of Fraud Dr. Muhamad Rifai [3:00]to individuals in rural nursing homes in Pennsylvania through telehealth. By 2022, basically, they decided to indict me for health care fraud, which was basically kind of just the significant blow to our practice, kind of almost imploded. I believed that I didn't do anything wrong. I believed in the validity of the services that I provided, that they were appropriate, that they were compliant. And I decided to go to trial. In May 2024, I went to trial. And after a six-day trial, the jury came back in two hours and found me not guilty. Dan King [3:39]What was the precise allegation from the DOJ? Dr. Muhamad Rifai [3:41]So the precise allegations were four charges of health care fraud and the specific codes that I was charged with, they were all the same codes. Four services of the same code is 90833, Evaluation and Management Code 90833, which is add-on psychotherapy, which is an add-on service to evaluation and management services that we did for nursing home patients. And the theory from the Justice Department was that basically these services never happened, that we upcoded and we overbilled for these services. Basically, they decided that these services were not valid. And... Extrapolation. So these were four services. Each one was worth $43.46. So four charges of healthcare fraud, each worth 10 years of incarceration. So they were going for 40 years in prison for $43.46, less than $180. And they extrapolated that amount to an amount of $1.3 million. dollars. They wanted $1.3 million, extrapolating it over several years. [5:02]The Trial and Vindication Dr. Muhamad Rifai [5:00]And so that was the indictment. Wow. Dan King [5:02]And so you were vindicated. Congratulations, by the way. Dr. Muhamad Rifai [5:06]Thank you. Thank you very much. Dan King [5:07]You were vindicated. Why, given that you were completely vindicated, there were in the end no issues, why do you think they brought these charges against you? Dr. Muhamad Rifai [5:17]So there's a multitude of reasons. So number one, the investigative agency was actually the Office of Inspector General for the Department of Health and Human Services. In 2013, current procedural terminology, the CPT coding written by the American Medical Association for Psychiatry change. We used to have only two codes. We used to have the old 90862 and 90801. We only had an initial code and a follow-up code. And so basically to harmonize billing and coding with the rest of the medical world, the AMA basically moved psychiatry to utilizing the evaluation and management codes in addition to the psychotherapy codes. So we would have two codes and the psychotherapy code is called add-on psychotherapy. So we had to understand a better, a more complexity of coding. Dr. Muhamad Rifai [6:13]Unfortunately, that information doesn't trickle to regulatory agencies. So the initial premise from the investigative agencies was that Dr. Refai was providing med check services. Now, med check services, which was code 90862, was eliminated in 2013. In 2015, they started this investigation and they said, well, he's only doing med check services. Why is he billing for psychotherapy? And nobody checked again on what happened with coding. And so the investigation started and it's a snowball and new agents came on board and nobody knew what was going on. And they basically lack of understanding of the of the coding scheme that we are rightfully utilizing. And even during that time, we had an attorney that reviewed, did a compliance review. We brought in an expert that looked at our records and thought that we were doing everything the right way. All of that didn't matter. All of that didn't matter because basically COVID happened and the political wind changed. Changed, and they wanted somebody who was doing telehealth to utilize. Dr. Muhamad Rifai [7:28]To indict, to teach a lesson with to everybody. It's like, okay, you do telehealth services not the right way, you go to jail. But there was a lack of understanding of the whole kind of coding structure of how our services were appropriately coded. The Department of Justice, I mean, whenever they indict somebody. Dr. Muhamad Rifai [7:47]98% of people plea. So they had very little chance that somebody was going to come back and say, what you're saying is wrong. You don't even know what you're talking about, which was our argument that the government didn't even know what they were talking about. The allegations were just baseless. And I only had two witnesses. I had a coder and a practicing psychiatrist. And our case was so strong that the government expert that they brought to testify on their case after we brought in these facts that the government's case was not right the government's the whole premise of what they thought that that i did was a fraudulent behavior that they were wrong they were completely wrong on the facts on the coding on the information the government's expert disavowed the government's case on the stand. She said, I don't support the government's case. I don't support this investigation from the minute it started based on this. And this is their own expert that they hired. That's when the trial turned around because like their own expert says, I'm not supporting this. And just their case tanked there. Dan King [8:58]Wow. Yeah. That doesn't happen very often. Dr. Muhamad Rifai [9:00]I was lucky with having a good lawyer that that kind of just strategize with me very, very well that that we should have we should have kind of held our cannons to to the the trial i i always during all of this ordeal i was like tell my lawyer well why shouldn't we we we're right everything we did was right can we go to them and tell them like listen we did everything right and said no no no because you tell them that they'll turn around and find some other contacts some other thing some other just just let's let's keep them where they are they they they're saying you're you're doing a psychotherapy cases that, that, that were fraudulent, let that be the case. And then because the, the coding scheme is so complex and the healthcare laws are so complex that they could come up with anything to, to just kind of add on. And you would have no defense to, to that. So if you're, if you're in the, in the clenches of the, of the, of the federal government, they're just going to get you. So. Dan King [9:59]And I can certainly understand with a 90% either conviction rate or 90 plea was it a 90 Dr. Muhamad Rifai [10:05]98 wow wow there's only one percent less than one percent are found not guilty so at 98 plea two percent go to trial one percent is found not 1.5 is found [10:21]Lessons for Group Practice Owners Dr. Muhamad Rifai [10:19]guilty and half a percent is found not guilty. Dan King [10:21]Interesting interesting so it is great then that you were not convicted what what lessons come out of this because you know we're not as interesting as legal strategy is, we got a podcast here for group practice owners. So what can group practice owners take away from this? What can they learn from this experience? Dr. Muhamad Rifai [10:39]So I think the value of early preparation, I mean, I think that, People need to have a robust compliance system. That's very important. I think, number one, they need to understand the rules and regulations as they are. And they are very opaque. They are outdated. And, for example, part of my case, because I went through this, we actually dug into the psychotherapy national coverage determination. So the Center for Medicare Services, CMS, basically publishes every few years guidance about what they will cover and the rules for what they would cover. And in October of 2015, with the transition from ICD-9 to ICD-10, they published an updated national coverage determination for psychotherapy. And basically, it's a it's a several page document that tells people basically what Medicare would cover and the rules of the of the road, how they would cover what you need to document for them to cover. And so what ended up happening is that that document wasn't updated. And we actually sent in for a FOIA or a Freedom of Information Act information. Dr. Muhamad Rifai [11:58]Basically, we asked CMS to tell us, well, tell us about this document. Who wrote this document? I mean, were people of the caliber of Dr. Aaron Beck or maybe Sigmund Freud's, Anna Freud's daughter? Participated in this drafting of the psychotherapy document. We sent the request and a year and a half after that request, like weeks before my trial, we got the answer and the answer was astonishing. Dr. Muhamad Rifai [12:30]And they said, we went back as early as 1995. We cannot find who drafted this document for us. We cannot give you that because I said, I want the names and the credentials of those. Maybe they could be witnesses that I could bring in and have them testify. They said, we cannot, we searched and searched and searched in our record and we have no records of who drafted or what's their credentials. So, I mean, so obviously somebody drafted the documents, but partially the reason why we asked for that is because the document was referring to the DSM-3R from 1987. Dr. Muhamad Rifai [13:09]And bsm-4 basically those kind of what were the frameworks of the of that document so i knew that that document hadn't been updated in a long time and so basically we brought brought that up it's like like the the guidance is not updated i think involving a coder, involving early on in somebody in somebody's practice it's very very important as well as bringing a coder on periodically to just do a spot coding check for maybe 10 records five 10 records every six months every year depending on the volume of that of that practice just so you can have a this is what i call a pulse check on your compliance with different rules and regulations For psychiatry, there's not a lot of rules and regulations. It's kind of people know what they are, the E&M code, psychotherapy codes, the procedure codes. I mean, there's very few. So it's not very complex. If you bring in a coder, they will be able to tell you, well, are you, for example, are you billing an evaluation and management code 99213 or 99214? Are you billing too many numbers? Dr. Muhamad Rifai [14:21]Maybe you're billing nice. Maybe those are appropriate. Maybe there's not appropriate. Maybe you have very complex patients where 99215 is appropriate. Maybe you don't have very complex patients where 99213 is appropriate. So just having that guidance from a coder, having that dialogue, having continuous training and education for providers, whether they're with one coding or whether you have a dedicated coder to understand and to understand what are the trends. Because certainly the regulatory agencies, the Office of Inspector General, the Center for Medicare Services, mental health is on the radar and it's big. And with telehealth, I mean, there's going to be, they want clawbacks. They want money back. It's not just Medicare. It's private insurers. Dr. Muhamad Rifai [15:12]They're going to audit things and they're going to come back at you and they're going to say, well, you know, we looked at 10 of your notes and we think four of your notes should have been a 99213 and you build them a 99214. Okay, here's, we're going to extrapolate for the last two years. Okay, here you go. Pay us $100,000 back. And how do you respond to that? I'm giving you a very, very real scenario that happens every day in every private practice, whether it's the Blue Crosses, whether it's Aetna, Cigna, United Healthcare. United Healthcare is even more difficult. For example, in the Northeast, they placed every mental health provider on a prepayment review. This is in the Northeast. Whether your billing was right, whether your billing was not right, everybody was placed on a prepayment review, meaning they need your records before you get paid. So I think that practices need to be very, very proactive in doing this. Dan King [16:10]That is super helpful, Muhamad. Thank you so much. Absolutely. A lot of this makes a ton of sense. And, you know, in our business, we counsel practices all the time to be very thoughtful about compliance and risk management. It matters so, so much. You don't think it matters until it's very obvious that it does. So in terms of things we can do, bringing in a coder for a spot check and internal [16:33]Navigating Compliance and Coding Dan King [16:30]audit is high on your list. I think that makes a lot of sense. Tell me in terms of you mentioned with Medicare. So, you know, they offer guidance. Is it a little spottier in your experience with private insurers, whether they offer guidance as regularly in the same way that Medicare does? Dr. Muhamad Rifai [16:47]It's very spotty. And so you don't know what they want until they come and audit you. And then they tell you, well, you missed this and you missed that. Sometimes they're okay in terms of like on the first episode and some insurance are not. Some insurance, depending on the size of your practice, some insurers will do an audit. and if you're at 90% or 85%, they'll let it slide. They won't ask for any recoupment. Some insurers know, depending on your size, if you're at 85% or 90%. I mean, and I can tell you, like one medical record, you could have two differing opinions from two different coders. And that's why it's very important to have guidance, to have your own coder. If, for example, if you were audited it from a private insurance and you have an attorney and you have a coder and then you can say, well, you know, I'll have my attorney and my coder have a composition with your coder. Maybe your coder can convince my coder that they're wrong or the other way around. Or maybe we just kind of figure out that that's a non-issue, that everything that we're doing is right and that and it's a non-issue. Dr. Muhamad Rifai [18:00]I think it's very important to have that investment. A coder, hiring a coder and an attorney is very, very expensive. But I think it's a worthwhile expense on the front end to be able to fend off those attempts from insurers to recoup money from practices. And it happens depending on size. Dan King [18:20]One of the strange, it makes total sense to me, and I couldn't agree more. And one of the strange things about healthcare is that you could argue, especially if we're an insurance-based business that we have two customers, right? We have our patients and we also have insurers. And the thing about insurers is, you know, when you're thinking about your own business strategy, if you do a lot of business with one particular insurer, there the case becomes even more compelling that you should understand what you're doing in terms of CPT strategy with respect to that insurer, [18:50]Proactive Strategies with Insurers Dan King [18:48]right? The investment there makes even more sense. And so I think it's so worthwhile for practice owners to look at, well, what are the insurance companies that we do the most business with and how can we make extra special care that in our relationships with those payers where things are really really bummed up especially if you know if you're struggling for cash you have to make decisions right and so that's maybe one way to think about things sure Dr. Muhamad Rifai [19:10]And and i i have uh in my in my journey with with uh this this prosecution i i had an advice from one of the coders that she implemented with it with a practice a large practice and they had a relationship that expanded with one insurer in particular. And she actually implemented a brilliant strategy. They brought her on and she actually was proactive. She reached out to the insurer and said, listen, we are doing lots of services with you. I want to be proactive. I don't want this to be a got you moment. Here's what we're doing. Here's a sample of 10 of our notes that I think are compliant. Dr. Muhamad Rifai [19:55]They're randomly selected. Please tell me, do you think that we're on the right track or do you think that we need to change course? And if so, tell me in writing, why do we need to do this? So when you come back and audit us, we know what the goalposts are. We know what the parameters are. There's not going to be a surprise for us. There's not going to be a surprise for you. We're not going to see a lot of your patients and then all of a sudden exit your network or you kick us out of your network or you Refer us to the fbi for criminal prosecution, We want the parameters to be clear. And if it's a big practice, I think taking that proactive step is worthwhile. You would bring in a coder and you would pay them a few thousand dollars, but you would avoid hundreds of thousands of dollars of recoupments later on the line. Dan King [20:44]And not just the money, the stress, right? Because we all know practice founders tend to be sensitive souls. And when there's a clawback, when there's an audit, let alone what you went through, which is a whole other level of stress, right? Dr. Muhamad Rifai [20:56]Yeah, absolutely. The sensitive soul that is. Dan King [20:58]The typical group practice owner is going to suffer emotionally as well as the next. Dr. Muhamad Rifai [21:03]Absolutely. Absolutely. I know group practice owners that whether it's something like this, and they close the practice. They said, the hell with the practice of psychiatry. I'm done. Dan King [21:13]So how did you get through? Because you could have easily done. There could have been a gajillion moments during this, right? Absolutely. Where you said, I'm done. So what did you do mentally and emotionally to go through all this? Dr. Muhamad Rifai [21:23]I'm a spiritual person. I have a strong spiritual base and a strong belief in higher power. So prayer, meditation, before we started the podcast, I told you that I'd been involved in the legal system for a long time as an expert witness. So some of that, I drew on some of that experience. So I knew the legal system. I knew a little bit about the federal system, not the criminal side, but the civil side. But I had some legal information. So I was familiar with the legal system. I, for a long time, worked in hospitals and in Pennsylvania when patients are hospitalized involuntarily. You have to provide testimony to the court to get them committed, to get them psychiatrically committed, a civil commitment under the Mental Health Act. So I've testified so many times. I had legal experience. Dr. Muhamad Rifai [22:13]So I basically thought that with that experience, I could weather this. I was lucky because I had an attorney who actually was familiar with the psychiatric practice. His dad was a psychiatrist. His brother was a psychiatrist. So he knew the field of psychiatry very, very well. And I was lucky that he was my attorney and represented me, provided me with excellent defense because he knew the field of psychiatry. And we brought in very good expert witness. We had a coder, a master coder who testified on my behalf. We actually also took the testimony of a practicing psychiatrist who like looked at the case and his testimony is like, I don't know what they're talking about. This is bread and butter psychiatry that this guy is doing. What are you talking about? This is fraud. This is like what most psychiatrists do, like 90% of psychiatrists do. And you're telling me this is fraud? This is outrageous. Dan King [23:09]I want to underline, you know, I think it's great also that you had some personal practices that were helpful and no doubt group practice owners as clinicians in almost all cases will have their own practices and should double down on those. But beyond that, another thing I really want to underline is the importance of specialized advice here. So not all attorneys are created equal when you're dealing with something as terrible as you went through, or whether we're just trying to protect our practices, right? So when it comes to understanding who the right lawyer is, you know, you really, I can say as a former lawyer, it's so important to find someone who specialized. A lot of people think all lawyers are sort of created equal, but I can assure you that is very much not the case. Dr. Muhamad Rifai [23:47]And. Dan King [23:48]Whenever you're hiring any professional, let alone someone who's doing work that is this complex and sophisticated, it can be hard to know who the right lawyer is. So any words of wisdom you could offer to folks on if they want some good legal advice, even if they want to hire like a master coder, how do I find the right person? Dr. Muhamad Rifai [24:05]It's very hard to find coders that are master coders in mental health. During this journey that I went through, I was able to kind of collect the names of coders that specialize in psychiatric and mental health issues. I collected the names of several lawyers and several firms that do compliance checks. [24:33]Launching SHIELD for Legal Support Dr. Muhamad Rifai [24:26]And so I decided to start a firm to assist individuals with some of some of these journeys. The practice is called SHIELD, Support and Help in Ethical Legal Defense. I can help physicians. I can help practice owners who are on the wrong side of the law. I can help them navigate this. I can reflect some of my experience and give them some of some of the wisdom that I that I accumulated during this difficult journey and help them navigate through these rough waters. I'm also writing a book that's kind of going to be coming out sometime in July. Dr. Muhamad Rifai [25:01]The title of the book is Doctor Not Guilty. And basically, I just kind of talk about my journey and my story and how basically I could be helpful to people if they're interested in learning more about my experience and how I can be helpful to them in proposing experts that specialize in coding for psychiatry, Lawyers that specialize in defending psychiatrists and also if they need colleagues who are psychiatrists that could provide expert witness testimony in that field. My website is www.shield.expert. Dr. Muhamad Rifai [25:38]So it's I'm available for advice if people are interested in kind of learning about this. And I specialize in psychiatric services, but I also kind of have provided consultation to individuals who are going through legal issues or prosecutions, key terms for medical as well as psychiatric issues. Dan King [25:56]And I'm presuming the book will be available on Amazon. Is it available for pre-order now? Dr. Muhamad Rifai [26:01]Not yet, not yet, but Amazon, it's, it's going to be, it's going to be available pretty soon. So July, probably, probably by the 4th of July holiday, we're going to have the book ready and it's doctor not guilty and the whole story i tell i tell kind of the raw story of just what happened and how how [26:23]Finding Balance and Self-Care Dr. Muhamad Rifai [26:17]we beat this i probably have a um i maybe three or four other books that are coming on the way. Dan King [26:23]Well important work you're doing for sure you know that this has been a rich but but also heavy serious conversation so i'd love to end us on a on a light note and ask when you're not doing the important new work that you're doing with shield and when you're not when you're not working on Blue Mountain Psychiatry. What do you do for fun? Dr. Muhamad Rifai [26:40]Part of this journey, I lost track of kind of self-care, perfect self-care. So I'm back to riding my bike, my city bike. I go, when I go to work, I ride my bike from my home to my office. It's about five miles in a suburban area. So that is exciting to me every day. I like swimming. I live in rural Pennsylvania. We have a river, the Delaware River and the Lehigh River, and sometimes we swim in the river, and it's beautiful. Dan King [27:09]Fantastic, Muhamad. Dr. Muhamad Rifai [27:11]Another small piece of advice that I recommend to all practice owners is just to have a compliance manual. A live compliance manual that gets updated, that reflects the current trends, and have an employee handbook. That protected us a lot because people would understand what would happen and how they're supposed to behave when things happen. And a recent practice that I actually consulted with, basically, their employees were not trained to respond to requests for information from regulatory agencies. So they had an audit. They had a request for information and audit from the Uniformed Integrity Program contractor for Medicare. They had a request for 10 records and the employees didn't know what to do with that. So it kind of went by the wayside. After three requests, the contractor referred them to the Center for Medicare Services that suspended their payments. And so that got their attention pretty quickly. But payment suspension is basically an ocean liner that needs to turn around. So they were without revenue from Medicare for 12 months until they convinced Medicare back again to turn on the spigots. So very small things could have significant consequences. Dan King [28:35]An important note to end on. Thank you so much. Thank you for telling your story. And thank you for the cautionary note, which I think I know from experience is so, so important in our space. We just don't hear it often enough. You know, your typical practice owner is just not trained to think in these terms. And your cautionary note hopefully warns people about sort of both the worst case about what could happen and also gives them some suggestions about how to preemptively take care of what you're building. and that's your patience. So I think it's super important. Thank you again, Muhamad. Dr. Muhamad Rifai [29:06]My pleasure.