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Save Your Practice from Fraudulent Billing Practices

June 24, 2015

Save Your Practice from Fraudulent Billing Practices

Trust is the base upon which lies a good and steady relationship between physician and patient, and so too with the physician and the government. Although, a vast majority of physicians practice their profession with integrity providing high quality care, promoting efficiency and compliance, yet many physicians do get duped. This can happen due to unscrupulous professionals within the system who can exploit the system for personal gain, especially in the medical billing department which leads to fraud and abuse of the system.

However, physicians should remember that violations of the Federal False Claims Act (FCA), the Anti-Kickback Statute, the Physician Self-Referral Law (Stark Law), the Social Security Act, and the U.S. Criminal Code often can result in nonpayment of claims, Civil Monetary Penalties (CMPs), exclusion from all Federal health care programs (including Medicare), and criminal and civil liability.

To keep the integrity of your billing practices intact, the physician first needs to know how and when a billing fraud can occur:

  1. Improper billing for medical services not rendered- like upcoding or phantom billing
  2. Medical Services perhaps rendered by an unqualified employee
  3. Attempting to bill for an evaluation and management service for the day after surgery or service bundling
  4. Self-referrals which the Stark Law explicitly prohibits

So how can you, a physician, save your practice from Fraudulent Billing? Here are 6 simple ways through which the physician billing services can be made effective and compliant:

  1. Internal Auditing and Monitoring:
    Conduct regular internal auditing of your systems. Keep records and use the OPEN PAYMENTS Mobile for Physicians app, as suggested by the Dept of Health and Human Services. This helps to track payments and other transfers of value you receive from applicable manufacturers and applicable Group Purchasing Organizations (GPOs)
  2. Implementing compliance:
    One such way is by efficient documentation. Every physician needs to document medical records of all patients that pass through the system. These may be called upon to assess past medical histories of the patient, and thereby assess appropriate care that you would have provided to the patient in the past, protecting your integrity if and when your billing practices may be challenged. Monitoring and enforcing proper billing medical services ensures a proper code of conduct for employees to follow
  3. Implement effective practice standards:
    This is relevant especially in relationship between Physician and vendors/health care ventures, with respect to Federal Government and Medicare beneficiaries. Try not to expose your patient to excessive and unnecessary referrals, or expose or refer them to products of a health care business that you have invested in. Take special care to implement reliable tracking systems so that your free samples are not mixed with your commercial stock of medical supplies.
  4. Proactive Outsourcing:
    Besides internal auditing, it is always good to get a second and objective opinion. This can easily be done by outsourcing your medical billing services which will match the compliance standards. Designating a compliance officer, tracking of new laws and regulations makes it easy to monitor your systems. Moreover hiring outside attorneys, consultants and financial auditors may be expensive in the short term, but in the long term this prevents fraud and gives peace of mind.
  5. Conducting appropriate training for the Employees:
    Having workshops for employees, apprising them of the processes of how billing and coding issues should be addressed, and how compliances should be adhered to on a regular basis, keeps employees in the know and the consequences of fraud and abuse of the system.
  6. Implement recommended protocols:
    By ensuring a strong disclosure protocol, health fraud and billing errors can thus not only prevent tension and loss of practice time, but also loss of money when associated with government claims. Also, enforcing disciplinary standards and developing corrective measures towards detected offences goes a long way in building a strong compliance system.

The above mentioned ways can help you save your medical practice from fraudulent billing practices

  • Total Focus on your medical practice
  • Cost optimization and revenue maximization
  • Risk aversion & Superior Compliance

Category : Best Billing and Coding Practices