Most physicians strive to work ethically, provide high-quality medical care to their patients, and submit proper claims for payment. Trust is at the core of the physician-patient relationship. The Federal Government also places enormous trust in physicians. Medicare and other Federal health care programs rely on physicians’ medical judgment to treat patients with appropriate, medically necessary services.
“Federal health care programs rely on physicians to submit accurate claims when requesting payment for Medicare-covered health care items and services. The presence of some dishonest health care professionals who exploit Federal health care programs for illegal personal gain creates the need for laws that combat fraud and abuse and ensure appropriate quality medical care”- As mentioned in a document ‘Avoiding Medicare Fraud-Roadmap for Physicians’ from www.cms.gov
While active Medicare abuse is a massive problem, there are many more times that a practice simply has sloppy business practices that lead to simple oversights — such as failing to understand government reporting regulations or claims that simply don’t add up. Unfortunately, even the most innocent practice provider is still liable if business practice mismanagement causes unintentional Medicare fraud. Even if you believe that you’re doing everything right — providing legitimate services and billing accordingly — your practice may still be charged with health care fraud. Essentially, good intentions will no longer keep you out of trouble with regulatory agencies.
The Centers for Medicare and Medicaid Services (CMS) recently published a high-level overview targeted to help physicians stay within the spirit and the letter of the laws around Medicare and Medicaid billing. The following Federal fraud and abuse laws apply to physicians:
Federal False Claims Act (FCA):
The civil FCA protects the Federal Government from being overcharged or sold substandard goods or services. The FCA imposes civil liability on any person who knowingly submits, or causes the submission of, a false or fraudulent claim to the Federal Government. An example may be a physician who knowingly submits claims to Medicare for medical services not provided.
Anti-Kickback Statute (AKS):
The Anti-Kickback Statute makes it a criminal offense to knowingly and willfully offer, pay, solicit, or receive any remuneration to induce or reward referrals of items or services reimbursable by a Federal health care program. Where a provider offers, pays, solicits, or receives unlawful remuneration, the provider violates the Anti-Kickback Statute. Remuneration includes anything of value such as cash, free rent, expensive hotel stays and meals, and excessive compensation for medical directorships or consultancies. If an arrangement, however, satisfies certain regulatory safe harbors, it may not implicate the Anti-Kickback Statute. Civil penalties for violating the Anti-Kickback Statute may include penalties of up to $50,000 per kickback plus three times the amount of kickback. Criminal penalties for violating the Anti-Kickback Statute may include fines, imprisonment, or both.
Physician Self-Referral Law (Stark Law):
The Physician Self-Referral Law often called the Stark Law, prohibits a physician from referring for certain designated health services payable by Medicare or Medicaid to an entity where the physician (or an immediate family member) has an ownership/investment interest or a compensation arrangement unless an exception applies.
Criminal Health Care Fraud Statute:
The Criminal Health Care Fraud prohibits knowingly and willfully executing, or attempting to execute, a scheme or artifice in connection with the delivery of or payment for health care benefits, items, or services to: Defraud any health care benefit program; or Obtain (by means of false or fraudulent pretenses, representations, or promises) any of the money or property owned by, or under the custody or control of, any health care benefit program. Penalties for violating the Criminal Health Care Fraud Statute may include fines, imprisonment, or both.
Civil Monetary Penalties Law (CMPL):
The Civil Monetary Penalties Law authorizes CMPs for a variety of health care fraud violations. The CMPL provides for different amounts of penalties and assessments based on the type of violation. CMPs may assess up to three times the amount claimed for each item or service or up to three times the amount of remuneration offered, paid, solicited, or received. Violations supporting CMPL actions include:
- Presenting a claim you know, or should know, is for an item or service not provided as claimed or is false and fraudulent
- Presenting a claim you know, or should know, is for an item or service for which Medicare will not pay
- Violating the AKS
To avoid such issues, Medical Biller and Coders (http://www.medicalbillersandcoders.com) suggest conducting audits on a sampling of charts at least annually to monitor compliance; Focus, especially on high-risk areas.
- Establish documentation standards and procedures
- Routinely ensure all contracts remain in compliance and they have not expired
- Designate a compliance officer
- Train and educate
- Communicate and implement disciplinary standards