Physicians are getting penalized for committing medical frauds including money laundering, conspiracy to commit fraud and aggravated identity theft. According to The National Healthcare Anti- Fraud Association financial losses each year is in tens of billions of dollars due to these fraud.
Around 243 individuals in 17 districts were penalized in the recent Medicare fraud sweep. The Centres for Medicare and Medicaid (CMS) have suspended numerous healthcare providers under the suspension authority provided by Affordable Care Act.
Here is the list of common healthcare provider fraud schemes:
- Billing those services which are not rendered
- Wrong representation of locations of service
- Billing for non covered service under covered service
- Incorrect provider of the service rendered
- Incorrect reporting of procedure or diagnosis
- Overutilization of services
- Unnecessary or False issuance of drugs prescription
ARE PROVIDERS INTENTIONALLY DOING THIS?
Indeed there are cases where the physicians get greedy or Medicare providers intentionally bill for any service or fictitious patient. However, at times these frauds can take place unintentionally and can lend the healthcare provider into trouble.
- Many times exaggerating patient’s condition, reporting symptoms that are not included in the diagnosis or changing diagnosis of patient’s billing to help them in securing coverage for the care required is done by physicians. These altruistic gesture from your end can lead you in great trouble. According to the law, your fate will be decided on the amount of negligence shown by irrespective of your intent.
- Inappropriate billing workflow can lead to fraud. Billing under NPI is very common, you need to fulfill certain criterias in order to bill under physician’s NPI. Be aware to meet ‘incident to’ criteria while billing under NPI.
- Different policies are introduced by States to what constitutes insurance fraud. In few cases waiving copayments come under medical fraud. We recommend you to be aware of the state regulations and keep on reviewing the new reforms introduced in the policies and procedures. Routinely waiving these charges, not only protect you from committing fraud but will simultaneously protect your practice from getting hurt.
- An effective EHRs help in creating complete documentation of the past notes. Make sure that the services that you actually offering are documented. Just for the sake of upcoding, if you are documenting in a wrong way then you are leading the way to claim denial together with insurance fraud. Make sure to document those service that are been rendered to the patients. You need an expert’s hands for knowing how to avoid over documentation in your EHR. Merely EHR software will not help you in escaping from committing fraud, you need experts that know how to leverage this technology.
Healthcare fraud affects your practice immensely. Keep the points in mind to avoid the problem of medical fraud as it can’t be overlooked.