Cracking down on fraud, waste, and abuse in government health care programs has taken a front seat in the U.S. government's drive to control health care costs. To wit: The Medicare Fraud Strike Force, a joint effort of the U.S. Health and Human Services and Justice departments, indicted 111 people for $225 million in Medicare fraud, including seven from Texas, in February. While none are physicians, doctors are on federal auditors' radar.
Here are the top six things they are looking for as indications of possible fraud:
- High number of claims for one procedure,
- Consistent billing at the same level or code,
- An unusually large volume of claims,
- Routine procedures outside of your specialty,
- Questionable referral patterns, including accepting something of value in return for referrals, and
- Routine waiver of patient copays without determining financial need.
You can avoid being at risk for refunds, fines, or penalties in government health care programs by more fully understanding how to steer clear of inappropriate practices and what's at stake if you don't. TMA can help. TMA's on-demand webinar, Fraud and Abuse, looks at the definitions of fraud and abuse, how to steer clear of kickbacks, how auditors root out the problem, and fines and penalties.
Action, March 1, 2011