July 13, 2017, Attorney General Jeff Sessions and Department of Health and Human Services Secretary Tom Price, MD, announced the largest ever healthcare fraud enforcement action by the Medicare Fraud Strike Force. This action involved charging more than 412 people, which included 115 physicians, nurses, and other licensed medical professionals, for their alleged participation in healthcare fraud involving approximately $1.3 billion in false billings. "Healthcare fraud is not only a criminal act that costs billions of taxpayer dollars -- it is an affront to all Americans who rely on our national healthcare programs for access to critical healthcare services and a violation of trust," said Secretary Price. What safeguards can a medical clinic or healthcare organization put in place to prevent fraud from medical billing?
There are several safeguards that a medical clinic or healthcare organization can put in place to prevent fraud in medical billing:
1. Conduct regular audits: Regularly review billing records, claims, and payment processes to identify any discrepancies or suspicious activities. This can help detect fraudulent billing practices early on.
2. Implement strict internal controls: Establish internal policies and procedures for billing and coding practices to ensure compliance with regulations. These controls should include checks and balances to prevent errors or fraudulent activities.
3. Staff education and training: Provide comprehensive training to all employees involved in the billing process, including physicians, nurses, and other licensed medical professionals. This should include education on proper billing and coding practices, as well as awareness of potential indicators of fraud.
4. Utilize technology tools: Implement billing software and systems that have built-in fraud detection capabilities. These tools can help identify aberrant billing patterns and flag suspicious activities for further investigation.
5. Regularly monitor and analyze billing data: Continuously monitor billing data and analyze patterns to identify any anomalies or trends that may indicate fraudulent activities. This can be done through data analytics and predictive modeling techniques.
6. Conduct background checks: Perform thorough background checks on all employees involved in billing and coding processes. This can help identify individuals with a history of fraud or other misconduct.
7. Maintain strong internal communication: Encourage employees to report any suspicious activities or concerns about fraudulent practices. Establish clear channels of communication, such as hotlines or anonymous reporting systems, to ensure that employees feel comfortable reporting potential fraud.
8. Stay updated on regulations and guidelines: Keep up-to-date with changes in healthcare regulations and guidelines, including Medicare and Medicaid rules. This will help ensure that billing practices are compliant with the latest requirements.
9. Regularly review and update policies: Review and update billing policies and procedures regularly to reflect changes in regulations and industry best practices. This will help ensure that billing practices remain in compliance and can adapt to new fraud schemes.
10. Engage external auditors and consultants: Consider engaging external auditors or consultants with expertise in healthcare fraud prevention and detection. These professionals can provide independent assessments of billing processes and recommend improvements to prevent fraud.
By implementing these safeguards, medical clinics and healthcare organizations can help prevent fraud in medical billing and protect both their patients and the integrity of national healthcare programs.