Eli's Hospice Insider

Published on Thu Jun 18, 2015 PDF

Check out these misconceptions and why you shouldn’t keep believing them.

You could be lulling yourself into a false sense of security when it comes to your risk of fraud and abuse charges. If you’re like many providers, you’ve bought into these common compliance-related myths.

At best, if you put your faith in any of the pervasive billing myths, you’re putting your organization at risk of repaying money. At worst, you’re putting yourself under investigation for a fraud indictment, “which could either be civil or criminal,” said consultant Barbara J. Cobuzzi of CRN Healthcare Solutions, who shared over a dozen common misconceptions during the Audioeducator conference, “Anatomy of a Fraud Indictment and Ultimate Acquittal.” And remember — criminal charges could lead to jail time, even for non-executives like billers, Cobuzzi added.

Below are five of the most common misconceptions that could get you in hot water.

1. You’re safe because you have a compliance plan on the bookshelf. “Just because you have a compliance plan doesn’t mean you’re safe,” Cobuzzi said. “Your compliance plan has to be a living, breathing thing that you have to always be referring back to.” In fact, she adds, “a compliance plan that’s sitting on the bookshelf or sitting in a file on your computer that you are not following is actually more damaging to you than if you had no compliance plan. That compliance plan you have has to be part of an active engagement with your practice, and that’s so very, very important.”

2. Your MAC has always paid you and you have never been audited, so you’re safe from fraud charges. If you’ve avoided review, your contractor has just been paying you based on what you put on the claim. “They’ve never looked at the documentation. They’ve never had the opportunity to compare it,” Cobuzzi said. “So that doesn’t necessarily mean they don’t think something is not right in your operation, and sometimes when they’ve always paid you, they then start looking at patterns … and then that’s when they start doing the investigation.”

3. You’re not responsible for reading every single government fraud alert, article, compliance document, MAC bulletin and every other Medicare transmittal, because if they can’t prove you knew about the laws, they can’t prove you knowingly committed fraud. “Nope,” Cobuzzi said. “If a rule is out there, you need to follow them. It’s just like from a speeding perspective: If you’re on a road with a 50 mph speed limit and a sign drops the speed limit to 30 mph and you didn’t see it and you’re still going 50 mph and the police stop you, they can give you a ticket for going 30 mph in a 50 mph zone…it doesn’t matter if you saw it, it was there, it was your obligation to be aware of the signs. It’s the same thing with Medicare, Medicaid and the private payers because they then use the system to go after you if you don’t follow their rules.”

4. Only large providers are at risk of a fraud indictment. “To tell you the truth, most of the practices I’ve been working with and I’ve been helping are small practices … that have been either investigated, indicted and had problems with authorities,” Cobuzzi said. The authorities seem to go after small providers “because they know they don’t have the resources in the bank to go and fight them and they’re more prone to settle even when they’re not guilty.”

5. The U.S. attorney can and will only prosecute fraud and abuse having to do with Medicare and Medicaid. Don’t think you’re safe if you’re playing fast and loose only on the non-Medicare side. “I have been involved in cases where private insurance companies didn’t want to spend their own money to go after it, so they pointed it out to the U.S. Attorney,” Cobuzzi said. The attorney will then find some component of it with Medicare or Medicaid, and then they will go after the provider, prosecuting for both the private payer and the government payer.

Note: To browse Eli-sponsored Audioeducator conferences, go to www.audioeducator.com.