With the financial systems of our medical institutions as nuanced as they are, taking precautions against healthcare fraud must be equally as nuanced. Fraud cases cost medical practices substantial expenses in investigations and loss of reputation and business. Accordingly, all medical practices should have established plans to avoid fraud and protect themselves and the patients they serve.

What is Healthcare Fraud?

Healthcare fraud is defined by HIPAA as deliberately and willfully implementing or attempting to affect schemes to abuse the health benefits of medical programs or acquire any of the financial assets using fraudulent claims, presentations, or promises. If someone seeks to utilize or circumnavigate established healthcare systems for their own personal gain, it is considered healthcare fraud.

Legal Provisions Against Fraud

There are three major laws that are specifically designed to limit fraud in healthcare settings. These serve as primary pillars of and corollaries to more general fraud legislation. 

Federal False Claims Act

The Federal False Claims Act is the United States government’s primary piece of legislation against fraud. First implemented during the Civil War, the act imposes civil responsibility on individuals who deliberately submit or initiate the submission of fraudulent claims to the federal government. Under the False Claims Act, whistleblowers are provided with job protection under the qui tam provision if they are filing against a party that has defrauded the federal government.

Anti-Kickback Statute

The Anti-Kickback Statute is designed to inhibit those who solicit compensation or give or accept remuneration for services provided by federal health programs. In other words, the statute brings legal action against those who incentivize referrals of federal healthcare programs. Intentional or complicit remuneration prohibited includes drugs and supplies and other non-cash incentives.

Physician Self-Referral Law

Also referred to as the Stark Law, the Physician Self-Referral Law forbids provider referral to receive services payable by Medicare or Medicaid at an entity in which the provider has a financial relationship. This may include services in which a physician or immediate family member has ownership, an investment interest, or a reimbursement arrangement. Providers who violate this law may face fines in addition to exclusion from participation in federal healthcare programs. According to its strict liability statute status, proof of specific intent to violate the law is not required to bring legal action against the party in question.

Recommendations for Providers

The Office of Inspector General (OIG) offers several suggestions to providers for protecting against healthcare fraud and responding in its event. Follow these to promote compliance within your organization and trust both among staff and clientele. 

A Designated Plan

A stringent plan of compliance is a strong defense against healthcare fraud. This plan should include policies which support a healthcare facility’s adherence to enforcement and which innumerate methods to combat suspected fraud, i.e. claims processing. Make sure that contingency measures and regulations are written clearly and policies are defined adequately. The plan of compliance should be distributed effectively among the staff and trained upon regularly. 

Chain of Command

Have designated individuals to whom employees may go to report suspicious activity. A Chief Compliance Officer at minimum is a necessity, and other personnel responsible for monitoring organization and compliance should be available resources to ensure efficient communication and above-board procedures and transactions. These individuals should report to the governing body of the clinic or hospital.

Detailed Reporting Strategies

Procedures for medical fraud reporting should be well-maintained and documented. They should also be easily accessible to staff; consider the use of a hotline. Make anonymity protection measures a priority to foster immediacy and candidness when fraud is reported. 

Defined Response Procedures

Have an established framework in the event of health fraud and abuse charges. Make all employees aware of the disciplinary steps, up to and including termination and legal action, against those who breach compliance laws and policies. 

Frequent Audits

As with all good business practice, implementation of reviews and audits to monitor compliance tends to improve adherence. Track enforcement assiduously to minimize more serious auditing problems. In the event that employees must be retained or terminated due to reasons of fraud or noncompliance, ensure that investigation and remediation are systemic and thorough, taking measures to improve policy implementation if such is found to be necessary.

Guard Against Fraud

To protect your clinic or hospital against healthcare fraud, reach out to our medical billing services at Aspen Ridge Medical. We adhere to strict compliance policies to maintain ethical billing procedures to prevent fraud and abuse in the healthcare practices we serve. Give us a call today to begin.