Make a habit of two things: to help, or at least to do no harm.
© Hippocrates
Decency & transparency have always been central in medicine. Throughout the history of mankind, doctors have been putting maximum effort into treating their patients regardless of the circumstances. Healthcare providers have always been limited to the environment and technology of their time. Some have been lucky to be paid fairly for their constant self-sacrifice, while others have not. Luckily, we have finally reached the stage when physicians around the globe receive fair compensation from their states, keeping their financial well-being in good order.
In the United States, the Centers for Medicare & Medicaid Services determines a fair fee schedule for hospitals and individual providers nationwide. When determining a price to be paid for certain services, the CMS applies the most up-to-date standards to fulfill the needs of healthcare practitioners. As a result, the healthcare industry has become quite a profitable business even for those who only treat Medicare & Medicaid patients.
However, the world is far from being perfect. In 2020 alone, 1,148 had were investigated for fraudulent activities by the US Department of Justice, while 440 healthcare providers were convicted for fraud. The convicted practitioners have misused the monetary resources provided to them by Medicare/Medicaid. The following criminal activities have been reported:
• Upcoding
• Billing for services that have never been performed
• Inappropriate remuneration and referrals
• Excessive billing of medically unnecessary services
• Excessive charges
Together, these activities constitute healthcare fraud and abuse.
Fraud – an activity aimed at receiving excessive funds from Medicare by means of intentional misrepresentation of performed services and patient’s clinical condition. Fraud can be committed by individual practitioners in the same way as it would be done by large groups of healthcare providers.
Abuse includes activities that can directly or indirectly result in unnecessary costs to the Medicare program. For example, the above-mentioned excessive billing charges is a perfect example of abuse.
In the United States, the following legislation regulates these two types of criminal activity:
• False Claims Act (31 USC Sections 3729 – 3733) determines liability for fraudulent claims submitted to Medicare
• Anti-Kickback Statute (42 USC Section 1320a-1) prohibits unlawful remuneration for services in exchange for anything materially valuable
• Stark Law (42 USC Section 1395) determines liability for paid referrals
• Criminal Healthcare Fraud Statute (USC Section 1347) covers coordinated and willful acts or attempts of healthcare fraud
• Exclusion Statute (USC Section 1320a-7) describes the cases in which healthcare practitioners may be excluded from a list of Medicare-participating providers due to fraud or abuse
• Civil Monetary Penalties Law (USC Section 1320a-7a) covers the possible monetary liability for a variety of fraud-related violations.
It is noteworthy that none of these laws determine a “fixed” liability for fraud or abuse. Instead, penalties are imposed in accordance with the complexity of a crime, and the damages caused by a fraudulent provider to the Federal Government.
WCH Service Bureau would like to remind you that it is critical to report & bill only the services that have actually been performed. Your claims, as well as the medical records, have to be transparent and indicate a “real picture”. As it can be seen in the above paragraph, a penalty is inevitable for any kind of criminal activity.
