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Avoiding Medicare Abuse and Fraud in Your Medical Practice

August 22, 2017

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While most practices are making minor, innocent mistakes with Medicare billing such as transposing a number from time to time, significant abuse and fraud issues could land you and your practice in hot water with the government — even if you aren’t aware of the problems. There is a wave of new technology available that allows regulatory agencies to pinpoint problem areas more quickly and with greater accuracy. The Affordable Care Act designated several hundred million dollars to ramp up anti-fraud efforts including sophisticated data analytics, the employment of additional law enforcement personnel, and an intense scrutiny of claims before they are paid. Fraud sentencing is becoming stricter, including civil and monetary violation penalties for practices that don’t return overpayments, for instance. With all of the challenges around medical billing, how can you avoid activities that could be flagged as Medicare fraud and abuse within your practice? 

Medicare Fraud and Abuse

Active Medicare abuse is defined as over-billing Medicare for products and services that were inaccurately coded, double-billed or that were not medically necessary. Generally, fraud cases are much more serious than a simple billing error, and can be very damaging both to the physician and to the practice. If individuals other than the beneficiary utilize a Medicare card to receive services, or are the recipient of prescription medications or other products, this is also considered fraudulent or abusive activity. 

Business Practice Mis-management

While active Medicare abuse is a massive problem, there are many more times that a practice simply has sloppy business practices that lead to simple oversights — such as failing to understand government reporting regulations or claims that simply don’t add up. Unfortunately, even the most innocent practice provider is still liable if business practice mismanagement causes unintentional Medicare fraud. Even if you believe that you’re doing everything right — providing legitimate services and billing accordingly — your practice may still be charged with healthcare fraud. Essentially, good intentions will no longer keep you out of trouble with regulatory agencies.

Related Article: 3 Reasons Why Your Billing Company Should Provide Pre-RAC Audits

Roadmap for Physicians

The Centers for Medicare and Medicaid Services (CMS) recently published a high level overview targeted to help physicians stay within the spirit and the letter of the laws around Medicare and Medicaid billing. Below are a few of the recommendations from this publication: 

  • Anti-Kickback Statute: Stiff penalties and even imprisonment await providers who receive remuneration to reward referrals of items or services that can be reimbursed by Medicare or Medicaid. This could include cash, excessive compensation for consultations, expensive meals and hotel stays and more. 
  • Federal False Claims Act (FCA): Providers who act in deliberate or reckless disregard for the truth related to a claim — e.g. submits Medicare claims for services that were not provided — are liable for the cost of the claim plus $11,000 per incident. 
  • Exclusion Statute: Meant to protect patients, providers who have been convicted of Medicare fraud, patient abuse or a myriad of other felony convictions are no longer eligible for reimbursement under Medicare and Medicaid laws. 
  • Criminal Health Care Fraud Statute: Fines, penalties and imprisonment await providers who willfully and knowingly execute a scheme intended to defraud any government health care benefits program. 
  • Civil Monetary Penalties (CMP) Law: With tens of thousands of dollars in penalties per assessment, the CMP Law addresses the relationships between physicians with other providers and vendor relationships. 
  • Consulting: Physicians should always ensure that they are being fairly — but not overly — compensated for their time and services by pharmaceutical companies and others. 

Ready to tighten up your medical billing practices to ensure that you’re fully compliant with all government requirements? Call the professionals at M-Scribe Medical Billing today at 770-666-0470 or email for a free analysis of your practice’s needs. 


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