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Three things medical providers should know to prevent Medicare overpayment investigations

Medicare overpayment issues can have significant financial and legal implications for healthcare providers. Unfortunately, such claims are not uncommon and may be on the rise. A recent study predicts that Medicare overpayments may increase by 20% in 2023, translating to more than $75 billion in alleged overpayments. Medical providers are wise to take proactive steps to minimize the risk of triggering overpayment investigations and ensure they maintain a positive standing with Medicare.

Step #1: Maintain accurate and comprehensive records

Accurate documentation is the cornerstone of Medicare compliance. Providers must ensure they support all services billed to Medicare with clear, detailed, and timely records. Documentation should include the rationale for the service, the specific services provided, and the medical necessity for each service. It is also critical to keep up-to-date with the latest documentation requirements as they evolve.

You can help achieve this goal through:

  • Educating. Educate all staff on the expectations and importance of thorough and accurate documentation.
  • Training. Take time to implement regular training sessions on proper documentation practices.
  • Auditing. Conduct internal audits to ensure compliance with documentation standards.

When taken together, these three actions can help to better ensure proper record keeping.

Step #2: Watch for updates

Medicare billing and coding regulations are constantly evolving. It is imperative for providers to stay current with the latest updates to avoid billing errors that could lead to overpayment claims. It can help to regularly attend seminars, workshops, and continuing education courses focused on Medicare billing to better ensure you are up to date on current practices.

Additional steps to help keep current include subscribing to Medicare newsletters and updates from reputable sources.

Step #3: Implement a compliance program

The use of a comprehensive compliance program is helpful in the event you need to build a defense against overpayment investigations. Such a program should include policies and procedures tailored to prevent, detect, and correct billing and coding errors. It should also foster an environment that encourages employees to reach out to leadership with potential issues without fear of retribution.

You can help achieve this goal by establishing a compliance officer or committee responsible for overseeing the program. Develop clear internal policies and procedures for all aspects of Medicare billing and regularly review and update your compliance program to reflect regulatory changes.

Preventing Medicare overpayment investigations requires diligence, education, and a proactive approach to compliance. By focusing on accurate documentation, staying informed about billing and coding updates, and implementing a robust compliance program, medical providers can significantly reduce the risk of overpayment claims. While these practices demand time and resources, the investment is minor compared to the potential consequences of non-compliance. It is always more cost-effective to prevent an issue than to resolve one after it arises.

Attorney John Rivas is responsible for this communication.