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Can doctors protect themselves from allegations of fraud?

The health care market accounts for a large chunk of the nation's economy. Individuals in the United States spend trillions of dollars to meet their health care needs. As a result, it makes sense that prosecutors follow through on allegations of health care fraud.

The United States Department of Justice (DOJ) has had success pursuing these crimes. For every dollar the government spends pursuing these crimes, it is estimated to recoup 7 to $10.

These cases often extend far beyond clear violations. Although the government should hold those who blatantly violate the law accountable, other cases involve honest mistakes. The regulations are extremely nuanced and following the minutiae of these laws can be very difficult.

How do these cases start? Many of these cases are the result of employee complaints. Employees may feel their organization does not take their complaints seriously. They may reach out to government agencies to share their concerns. Employees can call an anonymous hotline and voice these concerns, potentially fueling a government investigation.

Unfortunately, employees are incentivized to voice their complaints. The employee can receive a monetary award if the complaint results in a conviction.

What can medical professionals do to protect their interests? Physicians can act to protect their interests. Some proactive tips to reduce the risk of allegations of health care fraud include:

  • Record-keeping. Make sure to diligently and accurately record patient interactions. Proper documentation is needed to backup billing. If a question arises, this documentation could make the difference between a dismissed allegation and a drawn-out court case.
  • Proper relationships. Make sure that any financial partnerships are not in violation of anti-kickback laws. Review these relationships and make changes as needed.

The current opioid crisis has also played a role in the increased focus on health care fraud crimes. The government has heightened its scrutiny of opioid prescribers. As a result, any physician that prescribe such medication is wise to review their practices.

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