Working Together to Prevent Medicare Fraud and Abuse: A Guide for Hospitals and Patients

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.

COMPLIANCE PROGRAMS:

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.

• Developing a standard procedure in written format, the policies to promote the commitment from hospitals and can address a potential fraud.
• A chief compliance officer and other staff may be helpful in monitoring and operating the compliance program and report to the hospital’s governing body.
• Continuous training program to the staff such as to fill the knowledge gaps of the staff.
• Process maintenance to receive any healthcare fraud reports and complaints.
• Making a proper system to respond to healthcare fraud and take necessary disciplinary actions against the staff who may involve in malpractices.
• System to audit and evaluate that can keep a track of compliance adherence which may in turn reduce issues.

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.

CLINICAL DOCUMENTATION:

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.

MEDICARE FRAUD PREVENTION TIPS FOR PATIENTS:

According to CMS, patients can prevent Medicare fraud by following the below tips:

• Protect your Medicare and Social numbers, just as how you safeguard your credentials of credit cards or any bank related material.
• Avoid providing the Medicare card or number to anyone except to the doctor.
  Avoid accepting any free medical care.
• Educating self about Medicare and knowing one’s rights to use them effectively and properly.
• Make use of your calendar to note the doctor’s appointments, date of tests that you may undergo.
• Be aware of the types of services and procedures that can or cannot be billed under your policy.
• Ensure that you are provided correct medication from the pharmacy.
• Double-check your Medicare claims and statements as and when you receive them.
• It is always better to report if you come across any instances of fraud or even have a slightest suspicion of fraud.