The nationwide Health Care Fraud and Abuse Control Program (HCFAC) was established in 1996 by the Health Insurance Portability and Accountability Act (HIPAA). The program is the result of a joint effort between several major law enforcement bodies–the Health and Human Services (HHS), along with the Department of Justice (DOJ). Together these two agencies jointly direct federal, state and local policing activities aimed at uncovering fraudulent health care claims.

With the passage of the Affordable Care Act (ACA), the federal government has allocated even more funds to the Health Care Fraud and Abuse Control Program than they’ve allotted in prior years. This includes increased claims scrutiny prior to payment, as well as an increase in the number of federal enforcement agents.

Honest Medicare Billing Mistakes Can Hurt Your Practice

When you’re a physician and your medical practice accepts patients, avoiding billing mistakes takes on a much higher priority. For instance, as a health care provider you probably use billing software to enter your billing codes. However, if a glitch occurs that causes your practice to incorrectly bill your patients, this could easily snowball into a much bigger issue.

As a matter of fact, it is often minor mistakes such as these that usually wind up causing the biggest issues for physicians. This is especially the case if the mistakes occur often enough in today’s climate of increased scrutiny.

Recent Medicare Reforms

New reforms have tightened Medicare and Medicaid enrollment. One of the most recent regulations requires the return of CMS overpayments within sixty days. There is also a Fraud and Abuse Compliance program for Medicare providers.

To make sure that your medical practice is in compliance with the new laws you should have a clear understanding of the federal statutes regarding fraud and abuse. The most important among these are the Civil False Claims Act, the Federal Anti-Kickback Statute and the Physician Self-Referral Act.

  • Civil False Claims Act – The Civil False Claims Act prohibits a provider from filing false claims in order to receive payments from government programs. The filer will be liable even if they don’t know that the claims are false.
  • Physician Self-Referral – Physician self-referral means that a physician cannot refer patients to a provider of health services if the physician or a family member has a financial interest in the entity.
  • Anti-Kickback Act – This law prohibits offering, giving or receiving remunerations in exchange for the referring of patients or services offered by a federal program like Medicare or Medicaid.

If you are a healthcare provider, it is highly recommended that you have a fraud compliance program, in place. This will help you to better shield yourself in the event that a violation occurs by mistake. Government officials advise that if your practice makes mistakes, more than likely it will involve the services they perform the most. If this results in overpayments that must be repaid, it could cause the health care provider’s finances to take a significant hit.

The government advises a practice to conduct at least annual audits on a sampling of charts in order to monitor their compliance with federal regulations.

Protect Your Medical Practice Today

If you’re concerned about whether your Medicare billing mistakes are enough to trigger the scrutiny of state or local law enforcement, don’t just continue wondering about it. Contact the Law Offices of Robert David Malove today!

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