Tuesday, September 28, 2021

How to Avoid and Report Medicare Fraud and Abuse

As we all know, Medicare fraud occurs when someone intentionally exploits the federal healthcare program for their personal benefit. Physicians, healthcare service providers, or just anyone whose line of work is related to healthcare are usually the culprit behind these.

If you are one of them or should you happen to know one of them, then this article can be your brief guide on how to avoid and even report them.


Get a Good Grasp of the Law

For physicians, it’s worth taking the time to learn the laws surrounding Medicare fraud and abuse. To make it easier for you, here are the five important federal laws that are applicable to physicians and professionals in the medical field.


False Claims Act (FCA)

Like other laws, you may face civil penalties, criminal penalties, or both. Depending on the severity of your false or fraudulent claim, you might be liable to pay a huge amount of penalties, damages, and even imprisonment.

An example of an FCA violation is when you knowingly file a claim to Medicare for the services you never provided or rendered.


Anti-Kickback Statute

Through this statute, any remuneration (e.g. cash, rent, meals, trips, etc.) you willfully receive, pay, or solicit for a referral is considered as a crime or a violation. Penalties can range from fines, damages, to imprisonment as well.

An example of an AKS violation is when you pay lower rent for your clinic in exchange for referrals.


Physician Self-Referral Law (Stark law)

The Stark Law prohibits physicians to refer patients to a “designated health services” payable by Medicare in which he or she has a relationship with.

An example of a Stark Law violation is when you refer a patient to a clinic you have invested in.


Exclusion Statute

The Office of the Inspector General can exclude you from participating in any Federal healthcare programs. This means that you can no longer practice or enjoy the benefits of healthcare programs like Medicare, Medicaid, and others.

You can be excluded from any Federal healthcare programs if you abuse or neglect your patient, have been charged for felony convictions related to any medical practice, and many more.


Civil Monetary Penalties Law (CMPL)

Defrauding or abusing any federal healthcare programs means you are liable and would automatically face criminal CMPL. This means that any violation can cost you between thousands to millions of fines, fees, and damages.


Avoid Medicare Fraud All Together

As a health service provider, it’s your responsibility to ensure that your practice or clinic is in compliance with the law.

To give you an idea of the things you should do, here are a few tips that you should follow in order to foolproof your clinic from any healthcare fraud and abuse

  • Routinely conduct an audit in your clinic

  • Have a manual or practice standards in place

  • Appoint a specific person in charge of all compliance

  • Immediately correct or report any detected offenses

  • Establish transparency and form open lines of communication for all your staff or employees

  • Routinely attend and conduct training on all your employees, including yourself  

It’s worth highlighting that training and education programs are important for everyone who is working in the healthcare industry. There are some instances where unintentional fraud can happen due to the lack of knowledge as well as an understanding of the law and how the healthcare system works.

For instance, upcoding or under coding is a violation that can sometimes be unintentional. Upcoding is misusing a code for higher reimbursement while under coding is the opposite. The best way to combat and avoid these violations is to keep yourself as well as your employees informed and up-to-date with the Current Procedural Terminology (CPT) codes.


Report Medicare Fraud

If all else fails and you happen to find yourself at a crossroads, then you should report to the authorities or get help from a healthcare fraud attorney immediately. 

Keep in mind that you can anonymously report to the Office of the Inspector General Hotline. There are also Whistleblower Laws that would protect you if the alleged chose to retaliate against you. On top of that, the OIG, Department of Justice, and the Department of Health and Human Services also established the Health Care Fraud Prevention and Enforcement Action Team to aid and strengthen the existing law combating fraud.

With that said, you should not sweep any healthcare fraud or abuse under the rug. Whether it’s intentional or unintentional, you should immediately report or respond with corrective action. This way, you can mitigate the risk and solve the problem before they even get bigger.

Keep in mind that almost everyone relies on these federal healthcare programs. So abusing or letting anyone abuse the system would just put pressure on the entire healthcare system, making it harder for everyone to receive the proper care they deserve. 

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