Wiki Who is liable for fraud committed in the practice?

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CatchTheWind

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If a practice engages in Medicare fraud or abuse (such as habitually writing off co-pays), is only the provider of the services held liable, or could the liability extend to the office manager and/or practice owner? I am looking for an actual link or quote from the OIG or some other indisputable source on this. Thanks!
 
Writing off copays is not a violation unless its done routinely, which could cause suspicion. A physician is free to waive copays if they individually validate the patients inability to pay. Patients are expected to pay co-pays and deductibles. Go to; HHS.gov website

All individuals are responsible for ethical and legal behavior in the work place. Non physician staff can be subject to fines and penalty, including exclusions for the violations, which is not limited to willful intent.

http://oig.hhs.gov/compliance/physician-education/intro.asp
 
there was an article many years back in The Coding Edge regarding coder liability, in this articel it was stated that if you know something is wrong and you fail to stop the activity or report it if it does not stop then you are equally liable.
You cannot write off co-pays. If the patient is not financially able to pay the copays, You may be required to notify Medicare before you can write them off, you need to check with your regional office before you declare financial hardship. Some will require the patient to prove the hardship and apply for Medicaid as well. It is not as simple as deciding that the patient is unable to pay and then write it off.
 
Reference the OIG/HHS Link that I referred to. In that resource it specifically states "Routinely waiving copays could implicate the AKS and you may not advertise that you will forgive copays. however, you are free to waive a copayment if you make an individual determination that the patient cannot afford to pay, or if reasonable collection efforts failed".

Individual practices or organization may have policies to not waive copays, however that does not mean its a violation to do so. Be prepared to show proof of attempt, or verification of inability to pay. This was also confirmed by a representative of the local FI for CMS.
 
My understanding regarding the permissibility of writing off co-pays for hardship matches Lisa's. We do require the patient to sign a Hardship Form, which our Practice Administrator approves or denies, but I have never heard of any requirement to notify Medicare or to prove the hardship and apply for Medicaid. Debra, do you have a source for this?
 
The kickback prohibition applies to all sources
of referrals, even patients. For example, where the Medicare and Medicaid programs require patients to pay copays for services, you are generally required to collect that money from your patients. Routinely waiving these copays could implicate the AKS and you may not advertise that you will forgive copayments. However, you are free to waive a copayment if you make an individual determination that the patient cannot afford to pay or if your reasonable collection efforts fail.

Keep in mind here when you are making 'reasonable collection efforts' it's more than sending a statement and saying you haven't gotten a response. All collection efforts must be documented (statements sent/ collection letters sent), phone calls must be documented, and the efforts must prove a genuine, not token, effort to collect and generally exceed 120 days.


My other question would be, what are you using to determine hardship as this is supposed to be an occasional exception- and do you have an established policy in place for all payers including self pay? Is is just a conversation between the patient and the office manager? Or do you have a process where in the patient has to fill out an application and provide financial documents showing their inability to pay so that you have some back up if this is ever questioned? (1040 based on low income ect).

https://oig.hhs.gov/fraud/docs/alertsandbulletins/121994.html

One important exception to the prohibition against waiving copayments and deductibles is that providers, practitioners or suppliers may forgive the copayment in consideration of a particular
patient's financial hardship. This hardship exception, however, must not be used routinely; it should be used occasionally to address the special financial needs of a particular patient. Except in such special cases, a good faith effort to collect deductibles and copayments must be made. Otherwise, claims submitted to Medicare mat violate the statutes discussed above and other provisions of the law.
 
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Thanks Lisa. That F&A guide is great; I'm glad you led me to that resource! However, I did not find anything in it that indicates that office staff will be held liable for F&A.
 
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