The Office of Inspector General offers advice for new health care providers to avoid fraud. Understanding Medicare and Medicaid fraud laws can help protect doctors from inadvertent accusations.
Review these tips to shield your practice from these challenges.
False claims
Under the False Claims Act, you can receive fraud charges for claims that you know or should have known are false. That means you are legally liable even if you claim you did not know you provided false information to Medicaid or Medicare. Review every claim submission carefully, as you can receive a fine of $11,000 for every incorrect item billed to these programs.
Incorrect coding
Careful billing can decrease your chances of committing Medicare or Medicaid fraud. Using the wrong code can increase reimbursement, considered an abuse of the program. For best results, hire an experienced, trustworthy professional to handle your insurance billing and coding.
Other types of billing and coding issues that often lead to fraud accusations include billing separately for services covered by a different fee, by a provider who cannot participate in federal insurance programs, that you did not provide, that an unqualified or inappropriately supervised person provided, or that were not medically necessary.
Solicited referrals
You receive discounted office space from a specialist practice in exchange for providing referrals. While this may seem like a harmless way to network, it actually constitutes fraud under the federal Anti-Kickback Statute. Similarly, under the Stark Law, which covers physician self-referrals, you cannot refer patients to any provider who has a financial relationship with you or any members of your family.
If your practice comes under investigation for Medicaid or Medicare fraud from the OIG, you have the right to defend yourself. Doing so can potentially protect your professional license in Texas.