Doctors face a variety of legal risks every day: malpractice, fraud, waste and abuse. These actually surpass the risk of malpractice and tax liability. But physicians participating in federal health care programs can and must minimize those risks, because failure to do so exposes them to severe criminal, civil and administrative penalties, as well as tarnishes their reputation and impact reimbursement. Here are some simple steps that can help you take control:
1) Review the red flags for fraud:
• Billing for services not rendered.
• Billing for a non-covered service as a covered service.
• Misrepresenting dates of service.
• Misrepresenting locations of service.
• Misrepresenting provider of service.
• Waiving of deductibles and/or co-payments.
• Incorrect reporting of diagnoses or procedures (includes unbundling).
• Over-utilization of services.
• Corruption (kickbacks and bribery).
• False or unnecessary issuance of prescription drugs.
Disputes often occur due to concerns about the adequacy of a provider’s documentation or the level of supervision over a service. Generally the provider is a repeat offender! Unfortunately it is assumed that physicians and their staff know all the statutes, regulations, and CPT codes, memorize the manuals, national and local coverage determinations, bulletins and fee schedules applicable to their claims. When participating in federal health care programs and government money is at stake, ignorance is not a defense. So what else can you do?
2) Create a culture of compliance. Be committed to compliance with education and training, random auditing, and detailed documentation. Let violators in the office know they will be held accountable and let “whistle-blowers” know there won’t be retaliation. Getting compliance right is a competitive advantage for your bottom line.
3) Pay attention to the OIG guidance. The U.S. Department of Health & Human Services, Office of Inspector General, publishes voluntary compliance guidance documents for physician group practices, find it here: http://oig.hhs.gov/compliance/compliance-guidance/index.asp
4) Attend to problems quickly. Compliance problems not detected or those ignored for a lengthy period of time will attract government attention and lead to large penalties.
5) Budget for compliance. Providers should ensure that adequate resources and time are devoted to compliance activities. Legal or consulting advice may be beneficial in developing a compliance plan and procedures, doing an audit or investigating non-compliance issues.
6) Use benchmarking. Do not be in denial, big data is being mined by interested parties to find offenders. Be proactive and compare your billing data to similar providers in your area to be sure you are not under- or over-charging or incorrectly coding and providing the proper level of care. Abuse involves substandard, negligent or medically unnecessary practices that increase the cost of health care. Abusive practices often indicate fraud.
Keep in mind that health care fraud and abuse control programs are designed to prevent, identify and prosecute unlawful billings by health care providers and insurers. Health care fraud is a misrepresentation or failure to disclose pertinent information. A false claim involves an intentional false representation that causes the government to pay more than is allowable and might land you with more than a slap on the wrist!
Contact our healthcare team for assistance with this or any other accounting and operational needs. We have a depth and breadth of experience in the healthcare industry whether servicing hospitals, physicians, MSOs, dentists and DSOs, concierge medicine providers, chiropractors and podiatrists, etc. Whether in New York or Florida, call toll free 855-534-2727.