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BUFFALO----A sports medicine doctor practicing in western New York has been indicted on charges of health care fraud.
Dr. Ezzat M. Soliman of Warsaw, an orthopedic surgeon and sports medicine doctor, has been charge with health care fraud in allegations that Dr. Soliman, rather than use his discretion to bill appropriately as required for office evaluation and management codes, directed that his office staff always bill at the highest code available without any regard to the level of service he actually provided to his patients. Medicare and other insurance carriers are financially harmed by billing in this manner.
Assistant U.S. Attorney Robert G. Trusiak stated that Dr. Soliman profited by billing in this manner. In order to obtain reimbursement for services rendered to patients insured by insurance plans, a physician's office must complete and submit claim forms to the insurance carriers, either on paper or by electronic media. The standardized form )requires the physician to list the medical service provided to a patient, the diagnoses of the patient which made the service medically necessary, and the date of the service.
The medical procedures performed on patients are represented on the insurance claim forms by five-digit numbers, known as procedure codes. The procedure codes identify the nature and complexity of the service provided. The procedure codes correlate to previously approved payment amounts. The procedure codes are listed and explained in detail in the "Physicians' Current Procedural Terminology" (CPT) manual, which is published annually by the American Medical Association. The CPT codes are designed for and used by health care providers in billing for services rendered to both government and non-government health insurance programs. A doctor is required to use his honest determination of the appropriate code. The physician's treatment notes maintained inpatient files must reflect the work/decision making to support the billing. Insurance companies are authorized to audit the patient files to verify billings.
The billing codes relevant to Soliman are the five-level evaluation and management codes ("E&M") utilized for office visits. The codes for treatment of established patients range sequentially from 99211 to 99215: the higher the number, the greater the reimbursement. The CPT manual sets forth the criteria for each billing code. The highest code (99215) requires comprehensive medical history (at least eight organ systems), social history (diet, smoking, drug/alcohol use, physical activity, etc), complex medical decision making and/or a comprehensive physical examination. 9-08-06
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© 2006 North
Country Gazette
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