Providers face multiple healthcare fraud and abuse laws at the local, state, and federal levels. Fraud and abuse cases in the healthcare industry cost billions of dollars a year. Healthcare fraud and abuse situations include submitting false claims; billing for medically unnecessary services; billing and coding errors; billing for services that were provided by unlicensed or uncredentialed providers; waiving co-pays or deductibles; providing patient discounts or other incentives to receive services; kickbacks or similar arrangements to induce referrals; claims that lack sufficient documentation; or claims for substandard care.
Healthcare fraud and abuse is a vast topic and providers should ensure that their billing activities are compliant with state and federal laws. Complying with the numerous regulations can be difficult for providers as they focus on a range of priorities, including care delivery, payer compliance, medical billing, and revenue cycle management. Without compliance processes in place to detect and prevent fraudulent activities, healthcare providers could face an investigation that may cost them their reputation and revenue.
Tips on Avoiding Healthcare Fraud and Abuse
Providers must take appropriate steps to avoid any fraud and abuse in private payer programs as well as government programs. Among other things, providers should primarily do the following:
- Knowledge of federal and state laws will help the provider to both ensure its own compliance as well as ensure that the payer does not overstep its rights concerning payment and/or recoupment. State laws applicable to private payer programs, including but not limited to those laws governing insurance fraud, kickbacks, patient inducements, claim submissions, insurer recoupment rights, appeal processes, relevant time limits, or statutes of limitation, etc.
- Know and comply with payer contracts, including but not limited to policies or other requirements referenced in the contract. Where possible, providers should negotiate contract terms in a manner that minimizes provider liability or at least ensures the provider is given a fair opportunity to challenge payer actions before the payor may recoup or offset payments. Network adequacy laws may give providers more leverage than they have previously had.
- If a provider has questions about billing or coverage, they should contact the payer then document the communication, e.g., send a confirming e-mail or letter to the payer representative confirming the substance of the communication, and advise the representative that the provider will proceed accordingly unless the payer instructs otherwise. Such communication may help avoid misunderstanding and protect the provider if there is a dispute in the future, including giving providers the evidence they need to establish waiver or estoppel that may bar claims by payors.
- Beware of any actions that would constitute fraud and abuse under laws applicable to federal healthcare programs, including offering inducements to patients, kickbacks to referral sources, mischaracterizing the services that were actually provided, misrepresenting the person who rendered the services, etc.
- Render and document appropriate patient care and maintain accurate records necessary to support the care rendered in case they are ever challenged. The state and federal laws generally apply to or arising out of truly fraudulent or abusive practices, not good faith efforts to render appropriate care documented through accurate records.
- Establish an effective compliance plan applicable to private payers as well as government payers. The OIG publishes helpful compliance program guidance for different provider types at https://oig.hhs.gov/compliance/compliance-guidance/index.asp.
- Providers should periodically review, update, and train staff concerning their compliance plans. Among other things, providers should affirm a culture of integrity and compliance and ensure staff understands their compliance obligations and that the provider will hold staff responsible for compliance.
Comply Payer Contracts
One of the tips discussed above was knowing and complying with payer contracts. For better understanding, we will discuss some of the terms in payer contracts. Common payer contract terms include,
- the requirement to collect co-pays and account for deductibles;
- submitted claims should be medically necessary; rendered consistent with the applicable standard of care; and supported by adequate documentation
- the payer’s right to offset or recoup amounts improperly paid; and
- the provider’s obligation to affirmatively self-report and repay overpayments or amounts that were improperly paid by the payer.
The contract may expressly subject the provider to payer audits, investigations, or other review processes. Some insurers may even expressly prohibit fraudulent or abusive practices such as prohibiting patient or referring provider inducements; alternatively, they may require the provider to comply with applicable laws and regulations, which condition may extend to federal or state fraud and abuse laws.
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FAQs
1. What is healthcare fraud and abuse?
Healthcare fraud and abuse involve illegal activities such as submitting false claims, billing for unnecessary services, or billing for services by unlicensed providers.
2. How can providers avoid healthcare fraud and abuse?
Providers should familiarize themselves with federal and state laws, comply with payer contracts, document patient care accurately, and establish a strong compliance plan.
3. What are some common fraudulent activities in healthcare billing?
Common fraudulent activities include offering patient inducements, misrepresenting services provided, kickbacks for referrals, and submitting false or incomplete claims.
4. Why is it important to comply with payer contracts?
Complying with payer contracts ensures that providers follow rules for co-pays, deductibles, medically necessary services, and documentation requirements to avoid penalties.
5. What steps should providers take to stay compliant in billing practices?
Providers should periodically review compliance plans, train staff, document all communications with payers, and self-report any overpayments or billing errors.
