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Protecting Your Practice Against HealthCare Fraud Allegations

Doctor and Businessman
Annual U.S. health care spending reached a total of $3.3 trillion in 2016, according to the Centers for Medicare and Medicaid Services (CMS). While much of this spending is legitimate, the National Health Care Anti-Fraud Association (NHCAA) estimates that fraud results in tens of billions of dollars' worth of losses annually. If you're a medical provider, take a look at the top ways to safeguard your practice against health care fraud allegations.

Understand the Issue
The first step to prevent fraud accusations is understanding the crime itself. Providers can commit health care fraud several different ways, so allegations could come at multiple levels of service. Health care fraud allegations may include:
  • Upcoding. This includes billing for a higher level (more expensive) service than the actual one provided. It can also include altering the severity of the patient's diagnosis to bill for a pricier treatment.
  • Identity theft. Like other types of identity theft, medical identity theft includes stealing personal information to create fake patients or bill for fake charges.
  • Altering non-covered treatments. This type of fraud includes altering a diagnosis to change something that insurance doesn't cover (such as a cosmetic procedure) to look like one that is medically necessary.
  • Increased billing. Insurance contracts state the maximum that providers can bill patients for. Billing for an increased copay or charging patients for services that the insurance has paid for is fraud. 
Along with these, any type of intentional falsification (whether it's of the patient's record or the claim itself) constitutes fraud.

Pay Attention
The key word when it comes to health care-related fraud crimes is intentional. While mistakes and misunderstandings aren't acceptable professional practices, they're unintentional and not true fraud. There's a difference between purposefully falsifying a patient's diagnosis just to receive a higher insurance payment and accidentally coding the chart incorrectly.

With the high cost of health care fraud, inconsistencies can raise red flags. Whether it's the patient who complains or the insurance company, something that may seem like a simple mistake can turn into a major problem. Stay on top of your practice's charting and billing practices, and watch out for clerical errors. This may mean tighter oversight of the billing department (or staff member) or implementing a new audit system.

Provide Instructions
Even though you might understand what health care fraud is and how to avoid it, some of your staff may not have the same information. If you're in a management position or the practice's actions fall under your authority (meaning that fraud charges will make you at fault), provide all staff members with clear, written instructions when it comes to patient charting, billing, and insurance issues.

Create a written code of conduct that outlines standards and all practice policies. If you're not sure what to include or how to word these guidelines, consult an attorney who specializes in health care fraud. Review the guidelines/instructions verbally and ask each staff member if they have questions - especially anyone who does your patient charting or billing.

Ask an Attorney
Legal consultation doesn't only need to happen when creating conduct standards and guidelines. Prevention is often the best strategy when it comes to reducing the risk of health care fraud allegations. Along with adding evaluations and other measures that can catch errors, get the legal advice you need to protect yourself.

Only a qualified attorney who specializes in this area can provide you with the steps to take. If someone does accuse you of health care fraud, having an attorney who you've already consulted with gives you an option for immediate help.
Do you need legal advice? Do you have a pending health fraud charge? Contact us at The Law Office of Ralph Torres for more information.