Wiki Potential Fraud?

Messages
13
Location
Idaho Falls, ID
Best answers
0
Hello!
I'm not an auditor, but I think I may have discovered a huge billing issue.
We have been paid for surgeries over the 2021 year when we shouldn't have. We are starting to see take back requests, but I took it a step further to see how many claims should have a recoopment. It totals about $37.5K.
I brought this to our office manager's attention, but she doesn't seem like she cares.
Where I have now discovered this, if no action is taken to notify these payers, wouldn't that be fraud?

Bonus if you can attach links. :)
 
Hi there, it is potentially fraud, but a practice that discovers overpayments and doesn't take action could be subject to investigations, accusations of fraud, CIAs and settlements that may be higher than the total overpayment (not to mention the big legal bills) without an admission to or conviction of fraud. The 60-day overpayment rule which was released in 2016 increased the risk of ignoring overpayments. Here's the rule, you can find articles about it online: https://www.govinfo.gov/content/pkg/FR-2016-02-12/pdf/2016-02789.pdf

One thing to note, practices have 60 days from the time they complete an investigation into overpayments to return the money, not 60 days from the first time they discover an overpayment.
 
Hi there, it is potentially fraud, but a practice that discovers overpayments and doesn't take action could be subject to investigations, accusations of fraud, CIAs and settlements that may be higher than the total overpayment (not to mention the big legal bills) without an admission to or conviction of fraud. The 60-day overpayment rule which was released in 2016 increased the risk of ignoring overpayments. Here's the rule, you can find articles about it online: https://www.govinfo.gov/content/pkg/FR-2016-02-12/pdf/2016-02789.pdf

One thing to note, practices have 60 days from the time they complete an investigation into overpayments to return the money, not 60 days from the first time they discover an overpayment.
Hey, thank you so much! This is extremely helpful!
 
Sure and good luck. This sort of event can be an extremely delicate situation, especially if people panic.

P.S. If you haven't already, take some time to review protections for whistleblowers. You probably won't need them but it can't hurt to know in advance.
 
It is advisable to be tactful and careful when using this word without investigation and confirmation. Just because a payer initiates a take back doesn't necessarily or always mean the billing or coding was incorrect or inappropriate. There should be internal policies and procedures employees were provided regarding compliance upon hire. Further, if you feel a direct manager or supervisor did not take action the next step would be the internal compliance department, director or executive. Companies should have anonymous reporting mechanisms in place such as a compliance or ethics hotline to call without retaliation before jumping to conclusions. Internal compliance departments will conduct an investigation which could involve audits, etc. to determine if the allegations being made are confirmed and next steps.

 
It is advisable to be tactful and careful when using this word without investigation and confirmation. Just because a payer initiates a take back doesn't necessarily or always mean the billing or coding was incorrect or inappropriate. There should be internal policies and procedures employees were provided regarding compliance upon hire. Further, if you feel a direct manager or supervisor did not take action the next step would be the internal compliance department, director or executive. Companies should have anonymous reporting mechanisms in place such as a compliance or ethics hotline to call without retaliation before jumping to conclusions. Internal compliance departments will conduct an investigation which could involve audits, etc. to determine if the allegations being made are confirmed and next steps.

Thank you!
I work for a small business clinic, so implementing policies or recognizing issues like this has been a bit of an issue, after moving from a cooporation. This is extremely helpful and I appreciate it all!!
 
If you did not identify the issue at all and your office were audited it would be hard to say fraud was committed because the intent would have to be proven. Most cases in FWA ends up being a Waste or Abuse situation. However, since you identified the error if you dont correct it and you get audited then yes, you could be accused of fraud. Hope this makes sense Good luck!
 
I have many credits that have not been paid. Different scenarios, but many are patients that have a primary as well as Partnership. Primary pays primary, PS is billed secondary with EOB, but pay as primary. The other one I have many of is patient has 2 secondaries and both pay, leaving that small credit. I have been processing these as refunds to Partnership, but I would like to know if there is any reason I would not have to refund them. They have not requested the money back. I am just closing out the books, as our billing has been outsourced. There are many credits that were never processed that are several years old and forward.
 
Top