Identify Your Own Fraud and Abuse Red Flags

One way to help keep your practice operations squeaky clean and in compliance with fraud and abuse laws is to develop an internal set of warning indicators. These might include:

Significant changes in the number and/or types of claim rejections and/or reductions,

  • Correspondence from carriers and insurers challenging the medical necessity or validity of claims,
  • Illogical patterns or unusual changes in coding patterns or usage, and
  • High volumes of unusual charge or payment adjustment transactions.

If any of these warning indicators become apparent, the practice should follow up with an internal assessment, and take corrective action, if necessary, as outlined in the practice’s compliance plan. This means both:

  • “Setting things right” — for example, in the case of overpayments, prompt identification and repayment to the affected payer, or in the case of a potential criminal violation, referral or disclosure to an appropriate government authority or law enforcement agency; see the U.S. Health and Human Services Office of Inspector General’s (OIG’s) Practitioner Self-Disclosure Protocol (PDF).
  • Making sure the violation isn’t compounded or repeated. Should the individuals involved be retrained, disciplined, or terminated 

Avoiding fraud and abuse is a serious matter, as is knowing how to respond if a government audit flags your practice for an investigation. Fortunately, help is available. 

  • OIG’s Compliance Program Guidance for Individual and Small Group Physician Practices (PDF) is a seven-step set of voluntary guidelines.  
  • OIG offers A Roadmap for New Physicians: Avoiding Medicare and Medicaid Fraud and Abuse along with slides and speaker notes for trainers.

In addition, TMA has a new book to help you understand what constitutes fraud and abuse — and how you can avoid such claims in your practice. It offers continuing education credit, including ethics:

  • Fraud and Abuse is a guide for physicians, with a focus on Medicare and Medicaid, that details the laws and penalties associated with health care fraud and abuse as well as how to proceed carefully with self-disclosure when warranted. Check out the table of contents (PDF). You can order a copy from the TMA Education Center.

Published Aug. 28, 2012

Updated Aug. 25, 2014


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