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The cost of Medicare and Medicaid Fraud to the economy is a staggering $140 billion. This is why the government does not take issues of Medicare fraud lightly. It simply cannot afford to. If you are a healthcare provider, you need to understand what constitutes Medicare fraud and how to stay on the right side of the law.
Medicare Fraud Explained
Medicare fraud involves healthcare fraud, false claims act, stark, and anti-kickback statues. The following activities constitute Medicare fraud.
• A healthcare practitioner knowingly submits false or misleading statements to obtain payments that they would have otherwise not qualified for.
• Individual’s solicit/pay/accept remuneration from patient referrals or medical supplies.
• Making prohibited referrals for certain medical services.
• Billing the Medicare programs for supplies or services not provided.
• Submitting false claims to the Board.
• Submitting claims for supplies or services for patients who do not exist. (Ghost patients).
• Up coding: this is billing a higher code than the service warrants.
• Billing for medical equipment that has not been prescribed by the physician.
• Billing for substandard and low-quality services.
• Performing tests and medical services that are not necessary.
• Duplicate billing.
• Unbundling: this is billing treatments and tests separately instead of following the bundling procedure.
• Submitting claims on behalf of an excluded provider who is not eligible to participate in the Medicare program.
• Making false statements so as to participate in the Medicare program.
• Violating Medicare provisions.
If a healthcare provider is caught engaging in any of these practices, then they are immediately flagged, and inquiries are made into their actions. The reality on the ground is that few healthcare providers commit fraud intentionally. In most cases, the discrepancies arise from the complex billing systems that hospitals are expected to use. Minor issues can easily be detected by the healthcare board, and an audit into your business can be initiated.
When you receive notification for an audit, you need to engage with a Medicare, fraud lawyer. Sadly, even small mistakes can lead to a license suspension, or you can be charged a heavy fine. There is also a time period in which you are expected to respond to the audit officials. Failure to respond in a timely manner may be presumed as an admission of guilt.
Understanding Medicare Audits
If the healthcare board suspects you of fraudulent activities, they are mandated by Congress to make inquiries. The Medicare officials will move in to conduct an audit. The trigger may have been something amiss in your billing or coding system. This can be one entry or a series of entries that may have been flagged by the Medicare agents. There is no need for panic because in most cases, a mistake in the coding or billing system does not necessarily constitute to fraud. The Medicare audit team will investigate further to determine the legitimacy of the errors.
When the audit is over, the officials may grant a clearance letter. This shows that no fraudulent activities were detected.
However, if they discover fraudulent activities, your business can be fined, or you can be charged with a criminal offense. This is why you need to consult with an experienced lawyer. A license revocation could mean the closure of your business. If you are guilty of Medicare fraud, a lawyer can help to negotiate for a fine.
The importance of a Medicare Fraud Lawyer
Medicare and Medicaid audits are mainly conducted by Medicaid officials. In some cases, they may enlist the services of recovery audit contractors, who work on a contingency basis. These contractors are mainly motivated by financial gain. This makes your business a target. If a private contractor is tasked with auditing your hospital, you can be sure that they will be thorough and aggressive. These contractors are tasked with investigating nursing homes, medical clinics, hospitals, long-term care facilities, physical therapy establishment and home health agencies. It, is, therefore, in the best interest of your practice to seek legal advice from a Medicare, fraud lawyer.
The first course of action for the lawyer will be to establish the reasons for the audit. There are certain cases when the reasons for the audit are not clear. To counter the Medicare fraud claims, the lawyer will ask for documents which will be presented to the auditors. The lawyer will first analyze the document and prepare a defense based on the findings. During the investigation process, the lawyer will engage with the officials on your behalf. If you are guilty, the lawyer will immediately begin working on possible defenses to ensure that the doors of your clinic remain open.
The crackdown by the government on Medicare and Medicaid fraud exposes your clinic to a myriad of litigation issues. Without an understanding of the law, you may not be in a position to defend yourself. This is why enlisting the services of a Medicare lawyer gives you a good fighting chance.