You might just wonder what could be a fraud and abuse in Medicare reimbursement. Medicare fraud means claiming of the health care reimbursement where in the claimant may not even be entitled. Healthcare fraud and abuse can lead to legal consequences like exclusion from all federal healthcare programs and at times even the risk of losing professional license. Federal laws that govern Medicare Fraud and abuse contain the False Claims Act (FCA), Anti-Kickback Statute (AKS), Physician Self-Referral Law (Stark Law), Social Security Act and United States Criminal Code. Therefore such service providers must be careful about their medical billing outsourcing services.
The majority of billing practices such as improper ones highlighted by CMS which can be insufficient documentation, lack of medical necessity and incorrect medical coding. Healthcare facilities should be careful in protecting their organization from such kind of incorrect practices.
Hospitals can implement compliance programs that can keep the abusive practices at bay. Below are a few tips that providers may consider to avoid any kind of disasters.
It is a good practice to follow compliance program to maintain certain standards like appropriate coding policies and procedures, non-retribution policies, internal and external compliance audit standards and procedures, record retention policy, co-payment and deductible waiver policies, and code of conduct.
It is essential to have accurate clinical documentation and medical billing and coding for physicians to facilitate proper reimbursement for the services they provide. A recent survey shows that most hospitals are focusing on clinical documentation as well as implementing improving technologies and also achieved successful results.
To improve the medical billing and coding process, the staff must be properly trained and also provide them up to date training as and when there is any new process or code released. The refresher trainings play a critical role, it will help in reducing any kind of errors.
According to CMS, patients can prevent Medicare fraud by following the below tips: