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What could land you in hot water with Medicare and Medicaid?

On Behalf of | Apr 29, 2024 | Criminal Law

Medicare and Medicaid are vital programs that provide millions of Americans with healthcare access. Proper billing practices are crucial to help ensure their sustainability. However, even seemingly harmless mistakes can raise red flags and trigger healthcare fraud charges. This can result in serious consequences, including hefty fines, program exclusion and even jail time.

Medicare and Medicaid reimburse healthcare providers based on specific codes that reflect the services rendered. Upcoding (billing for a more expensive service than provided) and downcoding (billing for a less expensive service) are clear violations. However, the grey area lies in practices that may seem innocent on the surface level.

Reimbursement and compliance

To begin with, billing for services not medically necessary for the patient’s condition is a major concern. This includes ordering excessive tests or procedures or prolonging a hospital stay beyond what’s clinically justified.

Another concern is bundling, which involves billing for multiple services when only one was truly performed. For example, a routine office visit might include taking blood pressure, checking reflexes and discussing test results. If all three are billed separately, it could be seen as improper bundling.

There’s also wagering, which involves a physician referring patients to services (like labs or imaging) in which they have a financial stake. Conversely, split billing involves dividing a service fee between multiple providers when only one actually performed the work. Both practices raise concerns about conflicts of interest and potentially unnecessary costs.

Furthermore, submitting excessive bills or repeatedly billing for the same service can trigger red flags. This includes billing for services the patient didn’t receive or for services already covered by another claim.

Why seemingly harmless practices can be problematic

These seemingly minor errors can snowball into bigger issues. Inconsistent billing practices create vulnerabilities for overbilling and abuse.

To help protect yourself and your practice from healthcare fraud charges, you should make an effort to familiarize yourself with the latest Medicare and Medicaid coding guidelines and regulations. Additionally, you should invest in regular training for staff on proper coding and billing practices. This can significantly reduce the risk of errors and fraud.

Regular internal audits can also help identify and address any billing inconsistencies before they become bigger problems. Moreover, maintaining detailed records can help ensure accurate and complete medical records are kept for every patient encounter.

Healthcare providers can help ensure accurate and honest billing practices by understanding potential missteps and implementing proper safeguards. However, should you make unintentional mistakes despite your best efforts, you can benefit from personalized legal guidance to help avoid any serious consequences.