How to Detect and Prevent Healthcare Fraud
Health Care Providers should carry out extensive compliance programs and improve medical billing processes to identify and prevent healthcare fraud. The health care providers might encounter an inquiry that could fetch them a blemish for their career. It derogates their reputation as well as income.
HIPAA defines healthcare fraud as willingly and knowingly implementing or trying to execute schemes by following fraudulent representations and claims by any of the schemes of healthcare benefits.
To prevent fraud and abusive activities, the providers should follow all the healthcare fraud laws. They need to develop compliance programs and improve health billing and business transaction processes to stop an organization from involving in healthcare fraud and abuse activities.
According to the CMS, health fraud includes:
- Submission of the fake document to acquire reimbursements from payers for which they are not entitled.
- Requesting, receiving, offering, and paying remuneration purposely for the promotion or compensation of recommendation for items or services repayable by payers.
- Provision of illicit references to pertinent health facilities.
The Major Laws to Manage Healthcare Fraud and Abuse
In addition to finding the status of fraud for criminal health care, lawmakers have created three primary laws to control health fraud.
- Federal False Claims Act
This act is the imposition of civil responsibility on the person who deliberately submits claims to the federal government.
- Anti-Kickback Statutes
It aims at those people, who pay off, beg, offer or accept remuneration, willingly or unwillingly for the services referred to or reimbursed by the Federal Health Programs.
- Physician Self-Referral Law
It forbids referral to an entity in which the provider has ownership, an investment interest, or reimbursement arrangements for certain health care services reimbursed by Federal Healthcare Programs.
Tips to Prevent Healthcare Fraud and Abuse
A rigid compliance program is necessary to prevent fraud and abuse in healthcare. These programs are intended to establish a culture within a hospital to promote detection, prevention, and resolution of conduct that doesn’t fulfill the federal laws and national regulations as well as the hospital ethics or business policies.
OIG Recommendations for providers
The OIG recommendations also suggest the following components for the providers.
Creation and distribution guidance and policies written on authentic papers supporting the hospitals’ loyalty to enforcement and combating that fraud, like claims processing and financial ties with others. That is to say, it includes compliance with provisions in staff assessments.
- Reporting by the governing body of the hospital to the Chief Compliance Officer and other Organizational and Monitoring Compliance Personnel.
- Upholding of a medical fraud reporting and complaints procedure, such as a hotline, and development of anonymity or secrecy protection measures.
- Setting up a structure to respond to healthcare fraud and abuse charges and practical disciplinary steps against employees who break compliance laws and policies.
- The implementation of audits and reviews to track enforcement and minimize problems.
- Retaining the complete issue of investigation and redressing and policy implementation when workers are involved.
In conclusion, it is important to remember that the Providers must obey compliance guidelines directed by the Office of Inspector General. It applies to health personnel, medical equipment suppliers, and billers from third parties. The reporting, tracking, and billing consistency can improve the credibility and value of the provider. It must be ensured that any healthcare fraud must be detected immediately.