Coding and billing fraud are once again major targets for the Office of the Inspector General (OIG) and the Department of Justice.
There have been several high-profile cases involving coding and billing for physician services in recent months, and providers should make sure that their practices are in compliance with the law to avoid government audits.
Even though there are many tools marketed to physicians groups and hospitals that are intended make sure that medical coding and claims submissions are in compliance with Medicare and requirements from private payers, these tools may be giving health care professionals a false sense of security.
Health care providers may think that their coding and billing practices are compliant, but they could be overlooking unintentional or intentional errors that could lead to Medicare fraud charges, especially in larger practice groups or health care systems.
Some of the most common coding and billing violations that the OIG looks for include:
- Upcoding, which refers to assigning higher codes than necessary to explain a patient's condition or services they received.
- Billing for medical services that were not actually provided
- Billing for medical services that were provided but not needed
- Billing for medical services that were provided by an unqualified or improperly supervised employee
- Billing for medical services so poor in quality that they were essentially worthless
- Billing separately for services that were already included in a global fee
How compliance programs can help
To avoid problems, providers need to have compliance programs in place, and coding and billing processes should be audited and monitored on an ongoing basis. Compliance programs and ongoing monitoring and audits identify issues before they become serious offenses that can get the providers in major trouble with the law.
In fact, physicians who treat Medicare beneficiaries are required to have a compliance program in place under Section 6401(a)(7) of the Affordable Care Act.
Because health care's legal landscape is constantly changing, it is important to have an experienced health care attorney implement and oversee an effective compliance program, which should also include:
- Monitoring and auditing current coding and billing practices
- Designating a compliance officer or contact
- Training and education on compliance matters
- Handling potential compliance issues
At Rivas Goldstein LLP, we help physicians in Texas run their practices in compliance the law so that our clients can focus on what they do best: practice medicine. Keep reading for more information.