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Dodge Healthcare Fraud in Your Practice

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  • In Audit
  • May 17, 2018
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Dodge Healthcare Fraud in Your Practice

There has been a lot of focus recently on large fraud schemes uncovered by the government and many are wondering how this affects “me.”

By Evelyn Kim, MBA, CFE, CPC, CPMA, CRC, AAPC Fellow
Healthcare fraud is a thriving enterprise in the United States. The latest statistics from the Centers for Medicare & Medicaid Services (CMS) indicate it is a multi-billion dollar problem. In 2015 the government recovered 2.4 billion dollars in judgements, settlement, and administrative actions.

Why Should Providers Be Concerned?

Managed care organizations are developing special investigative units (SIUs) to audit and recover money paid by the health plan for services that are not documented appropriately. This means your documentation will be looked at under a microscope.
Health plans, especially those who are funded by the government (Medicare and Medicaid) are held accountable for every dollar spent to pay claims. They are looking closely a documentation to verify the services billed. This audit frequently results in refund requests and/or recouping funds from future payments.

How Do Providers Protect Themselves?

The best way for providers to protect themselves is by understanding the individual payer’s requirements for billing, documentation, and record retention. A sure way to have provider reimbursement taken back is to fail to provide documents when requested. Yes, the health plan has the right, even the obligation, to review the records of the people they insure, and the provider often must provide the documents at no cost to the health plan.
Once the provider has become familiar with the requirements, then a review of documentation habits and techniques should follow. For example: If the provider uses an electronic health record (EHR):

  • Does it meet the criteria set forth by the government?
  • Does it allow for proper patient identification?
  • Does it number each page?
  • Does it allow for free text when necessary?
  • Does it provide proper documentation of the provider’s signature?

Once it’s determined the EHR meets specifications, then the provider should look at their documentation habits. Waiting too long to sign the record could allow for alterations by someone other than the provider. Copy forward, copy and paste, etc., can make a record look cloned and result in denial for payment due to incomplete or inaccurate documentation.

Know Requirements for Specialty Providers

If the provider is a specialist, be sure the documentation accurately reflects the requirements for the specialty. For example:

  • Psychotherapy – It’s required to document the start and stop times for the session.
  • Obstetrics – The trimester needs to be documented.
  • Orthopedics – Laterality is important.

Remember for accurate diagnosis coding specificity is king. Without specificity, claims could be denied as inaccurate.

Intent Is Important in Fraud Cases

Once the above has been verified, how can the provider be certain fraud is not being committed? By definition fraud is the “intentional” submission of deceptive claims, a deliberate attempt to misrepresent the services provided for financial gain.
This does not mean fraud is committed every time the SIU reviews a note and determines it does not meet the proper documentation criteria. Often it’s simply a case of negligence or carelessness with no malicious intent. Intent is determined mostly by the type of documentation submitted, consistently “cloning” the record and all the documentation looks the same, or consistently up-coding or under-coding are just a few examples that suggest possible fraud.

Key Takeaways

  • Review provider documentation habits
  • Have a certified medical coder review the charges before submission
  • Be sure the documentation supports the services billed

Have an independent auditor come in and audit your records periodically. But most importantly, provide excellent patient care and document accordingly.
Author bio:

Evelyn Kim, MBA, CFE, CPC, CPMA, CRC, AAPC Fellow, works as the manager of SIU for Community First Health Plans. She has served as past president and vice president for the San Antonio, Texas, local chapter, and serves as member development officer for 2018.

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Michelle A. Dick, BS, is a freelance content specialist, providing writing, editorial expertise, and graphic imagery to clients. Prior to becoming a free agent, she was an executive editor for AAPC, editor-in-chief at Eli Research, and editor at Element K Journals. After earning a Bachelor of Science from the State University of New York at Buffalo State, Dick entered the publishing industry as a graphic artist, ad coordinator, and web designer for White Directory Publishers, Inc.

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