Tips To Avoid Medicare Fraud Investigation


By: Scott Rees
Good intentions will not necessarily save a healthcare provider from an investigation and charge of healthcare fraud.  Indeed, often times a provider will be charged with healthcare fraud even if he or she believed a legitimate service was provided and billed.  Mismanagement of claims, sloppy paperwork, and unintentional errors can all lead to a costly investigation.   The following identifies six ways to help prevent against unintentional healthcare fraud:
1) Billing with an expired license.  No license means no treatment, which makes the claim fraudulent.  This is true even if the license was expired for only a short period of time.
2) Not supervising closely enough.  Failure to properly supervise means the service was not provided.  Supervision requirements vary.  Obviously, it is important to know those requirements.
3) Patient did not pick up medications.  Prescribed medicine that is not picked up can be fraud if it is not credited back.
4) Billing clerk assumes certain services provided.  Improper billing due to sloppy billing processes or communication can result in fraud.
5) Helping poor patients with food or coupons.  This can be seen as an illegal kickback – an incentive to get patients to come back.  Safe harbor guidelines generally provide a single gift of $10, or $50 in one year, will not be viewed as a kickback.
6) Working too quickly.  Certain billing codes estimate certain amounts of time.  If a provider is billing too many of these in one day, it may be seen as improbable, and result in an investigation.
In sum, the physician and his or her office need to be involved in what is going on, and make sure they have systems in place to safeguard against these types of unintentional but potentially costly mistakes.