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June 30, 2020

Many lawyers will recommend to their healthcare provider clients they design and implement a comprehensive compliance program. One that will always work to improve their medical billing processes. The goal should be to prevent and detect potential healthcare abuse and fraud.

Legal Requirements
Healthcare providers must comply with a wide variety of abuse and fraud laws at the federal, state, and local levels. They must also continue to focus on revenue cycle management, delivering quality care, medical billing, payer compliance, and more. When some healthcare providers work hard to maximize revenue, they sometimes feel forced to engage in healthcare fraud. This can happen unintentionally. It may involve not correcting a billing clerk’s mistakes, billing for medications never picked up by a patient, and more.

Federal Government Remains Strict
It does not matter to the federal government if a healthcare provider did or did not intend to commit abuse or healthcare fraud. It remains very strict when it comes to punishing abuse and fraud. Health and Human Services (HHS) reiterated its determination to stop healthcare abuse and fraud. The federal government stated that the Centers for the Medicare & Medicaid Services (CMS) has initiated a program of proactive engagement of fraud protection. The federal government now utilizes predictive analytics to detect any false medical bills and to prevent healthcare providers from receiving unlawful payments. CMS is also increasing its efforts to properly screen providers prior to their enrollment in any federally funded healthcare program.

Compliance Program
One of the essential things healthcare providers should do to prevent and identify any possible abuse or fraud is to develop a strong compliance program. A successful compliance program will create a culture that encourages detection, prevention as well as identifies solutions for any behavior that doesn’t conform to federal, state, or local laws. This program should be a part of the healthcare provider’s business and ethical policies.

Improving Billing, Documentation and Coding Processes
The basis for payers reimbursing providers for services is clinical documentation. When coding is inappropriate or inaccurate, it can cause investigations into possible fraud and abuse. There are some common coding and documentation errors involving billing.

*Services already included in a global fee and not being separated. This includes codes service the day following surgery as well as management (E&M) codes.
*Billing for services that weren’t provided
*Providing procedures that are not medically necessary
*Providing tests or procedures that are considered to be very low quality or worthless
*Improperly supervised or unqualified employees performing services

To avoid these problems, a healthcare provider should be proactive. They need to evaluate their billing data and compare it to similar healthcare providers nationally, regionally as well as locally.

Value-based reimbursement is a common purchasing model. It promotes healthcare providers in developing business relationships with other organizations. This is an effective way to fill care gaps. Controlling care across the healthcare field enables healthcare providers to better monitor patient outcomes. They can also better analyze costs in order to maximize value-based reimbursement. The federal government does provide healthcare abuse and fraud waivers. This is for healthcare providers using value-based reimbursement models.

Inspector General (OIG)
There are certain components the OIG suggests healthcare providers implement in their organization.

*Investigation and remediation of any identified problems. Establish policies to handle retaining or terminating any involved staff

*Development and distribution of written policies and standards of conduct. These policies should explain the healthcare providers dedication to being compliant

*Utilization of evaluations and/or audits to identify adherence and compliance to decrease numbers of issues

*Developing a system to respond to accusations of healthcare abuse and fraud. Have actions for appropriate disciplinary actions in place against staff who violate compliance laws and policies

*Keep a process in place to receive healthcare complaints and fraud reports. This could be a hotline. A process to protect anonymity should also be in place. This will protect whistleblowers from any form of retaliation

*A Chief Compliance Officer should be appointed. Their staff will be responsible for monitoring and operating the compliance program. They should report to the hospital’s governing body

*Provide continuous training and education for staff

The healthcare industry is regularly developing new types of claims and delivery reimbursement standards. Because of abuse and fraud regulations, this will not change. Healthcare providers need to be certain their organization is current and in compliance with all new regulations. This is an effective way to avoid potential fraud investigations as well as criminal charges.



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