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How Doctors and Hospitals Can Combat Medicare and Medicaid Fraud 

Counterintuitive as it seems, it is possible to commit fraud without actual intent. If you and your staff lack careful billing and oversight processes, you could come under investigation for Medicare/Medicaid fraud.

If you bill for 30 patients on a given day but you actually only saw 20, the 10 phantom patient billings are patently fraudulent. But even a simple mistake or oversight, such as a billing clerk including a procedure code for a patient who didn’t receive that service, can be suspect. This could happen if your staff is accustomed to billing certain codes together and they assume you provided the same services to a particular patient when, in fact, you didn’t.

Another common issue is lapsed licenses. If you have a medical provider in your office — such as a doctor, nurse or technician — they should not be working during any lapse in their license, even as short as a day. Insurance companies routinely check license information during claims processing, and such a finding would tarnish billing to all your patients for that day, including those on Medicare and Medicaid. Regulators consider billed services by an unlicensed provider as services that never happened.

Similarly, if you operate a practice but are not present or readily available while certain patients are being treated, billing for those services could be deemed fraudulent because they lacked supervision.

Prescription billing is another area fraught with risk. If you billed for a prescription that the patient never received, it could be deemed fraudulent. To avoid inadvertent billing, have a system in place to flag billed prescriptions that were never picked up.

Physicians sometimes find themselves on the wrong side of the law due to financial arrangements that could be considered kickbacks or self-referrals, such as having a financial interest in another practice to which patients are referred. Even giving small gifts to patients could get you in trouble if the gifts are deemed a reward for continuing to use your services.

With the high risk of fraud investigations arising from inadvertent mistakes, it makes sense to work with a skilled lawyer to devise a compliance plan. If you have concerns about an aspect of managing your practice, contact a knowledgeable healthcare attorney at Hemmer DeFrank Wessels, PLLC.

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