How the Surge in Medicare Fraud Revocations Affects Physicians

According to HHS, since 2011, the federal government has revoked the ability of 14,663 medical providers and suppliers to bill Medicare, more than doubling the number from the two years prior. 

HHS Secretary Kathleen Sebelius credits President Obama’s Affordable Care Act for the recent upswing in Medicare reimbursement reversals. In fact, it has resulted in the recovery of almost $15 billion in Medicare fraud money over the last three years.

“By expanding our authority to suspend Medicare payments and reimbursements when fraud is suspected, the law allows us to better preserve the system and save taxpayer dollars,” said Secretary Sebelius in a press release.

The government plans to revamp efforts to prevent Medicare fraud by increasing the reward for reporting claim abuse from $10,000 to a potential $9.9 million and developing a new, easy to read the summary statement that permits recipients to see who has billed Medicare on their behalf.

“The new Medicare Summary Notice gives seniors and people with disabilities accurate information on the services they receive in a simpler, clearer way,” said CMS Administrator Marilyn Tavenner. “It’s an important tool for staying informed on benefits, and for spotting potential Medicare fraud by making the claims history easier to review.”

Even with these new measures, not all Medicare beneficiaries will be protected. Officials are still seeking a better way to redistribute Medicare identification numbers to the 284,000 patients who have had their information breached or stolen. 

What Doctors Need To Know
Even respectable physicians need to be concerned with Medicare fraud. Violations of Medicare laws can result in unpaid claims, Civil Monetary Penalties (CMPs), total exclusion from the Medicare Program, and even criminal and civil liability.

The three most important federal fraud and abuse laws you should be aware of are the False Claims Act (FCA), Anti-Kickback Statute and Physician Self-Referral Law (Stark Law). 

Under these regulations, healthcare providers can be excluded from participation in all federal health programs if convicted of Medicare fraud, patient abuse, felony financial misconduct, and felony convictions for unlawful distribution of prescription drugs or controlled substances. 

It’s important to realize that when submitting a claim for services performed on a Medicare patient, you are filing a bill with the federal government and are certifying you’ve rightfully earned the payment requested. Even if you merely “should have known” the submitted claim was fabricated, the attempt to collect unwarranted monies constitutes a crime. 

Some examples of improper claims submittals include: 

  • Billing for services not actually rendered 
  • Billing for services performed by an improperly supervised or unqualified employee 
  • Billing for services performed by an employee barred from participation in federal health care programs 
  • Billing for services of such low quality that they are considered virtually worthless 
  • Billing separately for services already included in a comprehensive fee, such as billing for an E&M service the day after surgery 

How Can Physicians Avoid Fraud
The best way to avoid fraud is to keep accurate and complete medical documentation for services provided. This way, you can address any challenges against the integrity of your Medicare claims.

Correct documentation also helps ensure patients receive appropriate care from other providers that rely on your records for a patient’s medical history. 

Also, be vigilant when distributing sample pharmaceuticals to patients. Many drug companies provide physicians with free samples they can give to patients for free. It is perfectly legal to distribute these samples to patients free of charge, but not to sell them. Recently, the federal government has ramped up prosecutions against physicians billing Medicare for free samples. 

If you’re looking for more information on avoiding fraud, contact an experienced health care lawyer. They can usually provide a legal evaluation and risk analysis of the situation in question. Both the legal bar association in your state and your state or local medical society may have listings of health care lawyers near you. 

CMS’ local contractor medical directors can provide quality information on Medicare coverage policies and appropriate billing practices. The “Medicare Physician Guide” is another valuable resource for information regarding Medicare reimbursement and payment policies. 

What To Do If You’re Suspected of Fraud
If you find yourself in a situation that may be problematic or have been following billing practices you now realize were wrong: 

  • Immediately cease filing the problematic bills 
  • Seek knowledgeable legal counsel 
  • Prepare for return any money collected in error from patients and from federal health care programs 
  • Undo the questionable billing practice by taking all necessary steps to free yourself of involvement 
  • Separate yourself from any suspicious vendor relationships 

No one provider is perfect, and the federal government understands this. But in order to save taxpayers from losing billions of dollars, health care agencies have to be very strict in the way they handle Medicare fraud. So remain watchful of your billing policies and report any suspicious practices you encounter.

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