Detecting and Preventing Fraud and Abuse in Healthcare Title Card
No matter where you are in the health field, it remains true that one of the most undermining practices is fraud and abuse. Anywhere you go, up or down the chain it is imperative that measures are taken to find and prevent fraud & abuse from occurring. To stay among the best medical billing companies, we take on our share of responsibility. We do our part to keep the industry honest and our customers safe.

Why Is This So Important?

Studies have shown that only about 5% of healthcare fraud is ever uncovered. It costs the industry billions and those costs get figured into what the customer pays. Failure to uncover anyone willfully and knowingly misleading benefits programs opens up medical billing professionals to legal liability. This is why we need to understand the laws and implement compliance programs to catch issues.

The Three Guiding Laws for Medical Fraud

There are three laws that represent our regulation of medical fraud. These include the Federal False Claims Act, Anti-Kickback Statutes, and Stark Law. Each represents a powerful tool in helping get the problem under control. Violators of these laws could face exclusion or financial penalties from federal healthcare services.
The Federal False Claims Act imparts civil responsibility on anyone who intentionally submits or triggers a false or fraudulent claim to the federal government. However, there are other types of Fraud to be taken care of as well.
Anti-Kickback Statutes are aimed at anyone who would compensate, solicit, give or accept payment, intentionally or willingly, for services referred to or reimbursed by federal health programs.
The third area of regulation is Stark Law, which makes illegal referrals to any entity in which the referrer has a financial interest and federal reimbursement is being used partially or in whole.

Recommended Steps

Guidance by the Health & Human Services’ Office of Inspector General says this strong compliance program is in place to establish an appropriate healthcare culture. This environment should include promoting: preventing, detecting, and resolving conduct that fails to comply with national standards. These standards are set by federal and state law as well as private health care and ethical business policies. The following individual steps are recommended:
  • Establish Organizational and Monitoring Compliance Personnel including a Chief Compliance Officer. This will report to the healthcare governing body
  • Create and distribute written guidelines and policies. This should support adherence to enforcement and combating suspected fraud.
  • Maintain a medical fraud reporting and complaints procedure. Creation of a hotline or development of anonymity protection measures would be included.
  • Set up a framework for healthcare fraud and abuse response. This should include practical disciplinary steps for reprimanding employees in breach of compliance policies or laws.
  • Implement audits and reviews in an effort to track enforcement and minimize problems.
  • Set in place a policy for investigation and remediation when employees are suspected to be involved or terminated.

In Closing

Adherence to the guidelines set forth by the Office of the Inspector General does not stop at staff personnel. Health personnel, medical equipment suppliers and third-party billers are all expected to bear their share of responsibility. Reporting, tracking, and billing consistency raise provider credibility. We do our part in ensuring that inconsistencies in billing or coding are addressed immediately.
If you’d like more information on this or any of the topics we share here, please contact us today at 1-800-795-1794 or 440-934-6135