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3 tips to avoid allegations of healthcare fraud

The United States Department of Health and Human Services (HHS) continues to crackdown on allegations of healthcare fraud. The government will strike both before and after the fraudulent activity occurs. Predictive analytics allow federal investigators to flag potential violations before they occur. This tool, paired with federal investigations, allows government agencies multiple tools to gather evidence to build support allegations of fraudulent activity.

Hospitals and private practices that operate in this environment are rightfully concerned about the possibility of accusations of violating healthcare law. Three tips that can help to reduce this risk include:

  • Understand the law. It is generally illegal to knowingly submit false claims or misrepresentations to receive reimbursement or intentionally encourage or reward referrals for services reimbursed by payers. This includes billing for no-shows and altering claims to bill for a higher service.
  • Have a compliance program. It is often beneficial to have a written policy that promotes a commitment to compliance. This can include the designation of a Chief Compliance Officer within the facility to better ensure the proper practices are in place.
  • Improve operations. Review the facility's billing system and make changes as needed to better ensure compliance. For example, the Centers for Medicare and Medicaid Services (CMS) encourages a review of billing to check for any potential upcoding violations. It is also wise to regularly compare billing practices with the market standard. The government looks for outliers. If the facility is not in line with industry standards it may be at an increased risk of a federal investigation.

It is also important to note that the regulations and laws governing the practice of medicine are evolving. The healthcare market is shifting towards one of coordinated care services. Although arguably better for the patient, the shift often finds itself in contention with regulations that can result in allegations of fraud - one notable example the Anti-Kickback Statute.

Healthcare providers who face these allegations have options. An attorney experienced in this area of the law can help discuss these options and build a defense to the allegations.

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