Maintaining compliance with Medicare and Medicaid regulations has always been a concern and priority for healthcare providers. The implementation of the Affordable Care Act increased resources available to the U.S. Department of Health and Human Services (HHS) for monitoring anti-fraud activities. More agents on staff means there are more eyes available to review claims prior to payment, therefore scrutiny has ratcheted up several notches. Also, HHS is now utilizing sophisticated analytics to identify red flags that demand further investigation.
HHS reported that in the last three (3) years, every dollar spent on fraud investigations results in the recovery of over six (6) dollars. That return on investment ensures that strict enforcement and investigations are here to stay.
Egregious cases of Medicare and Medicaid fraud, such as submitting claims for services never received by the patient, are pretty cut and dry. But healthcare providers should be careful that they are not inadvertently committing these other fraudulent acts:
- Billing inaccurately by coding the bill improperly.
- Misstating the medical necessity of a particular procedure.
- Failing to report or return any overpayments by the insurance company.
- Improper reporting of violations of anti-kickback or Stark Laws.
Perhaps the biggest mistake a healthcare provider can make is talking with Medicare or Medicaid fraud investigators without legal representation experienced in health law. Seek legal counsel with extensive experience working with healthcare providers and practitioners– experienced Medicare and Medicaid fraud defense attorneys who will know how to navigate the Medicare and Medicaid regulation landscape. Having legal counsel present when talking to investigators is not an admission of guilt. It’s just good business.