Healthcare providers should implement comprehensive compliance programs and enhance Primary Health Network Billing processes in order to catch and stop fraud and abuse in the healthcare industry. The healthcare industry is awash with billions of dollars every year due to healthcare fraudulent practices and abuse. Healthcare providers could be the subject of an investigation, which could ruin their reputation as well as income if they don’t have the processes in place to detect and block fraudulent activities.
HIPAA describes fraud within the field of health care as knowing and willingly trying to carry out schemes that rob the health benefits of a program or gain access to any money or property held by any healthcare benefits scheme with fraudulent or false assertions, promises, or claims. Healthcare providers must be aware of the essential fraud laws, establish compliance programs, and enhance Primary Health Network Billing and business processes to avoid an organization from engaging in health fraud and abuse.
Primary Health Network Billing
Healthcare Fraud and Abuse Laws and Regulations
There are many definitions and regulations that concern the improper use of billing by providers. The providers should be aware of the differences between abuse and fraud, and the specifics regarding the False Claims Act, Anti-Kickback Statutes, and the law regarding providing referrals to medical practitioners.
What are the elements that have included Healthcare fraud according to CMS?
As per the CMS Health Fraud includes:
Submit false information or submit false claims to obtain reimbursements from the payers to which there isn’t any entitlement. Offer, request, or receive and pay compensation for the purpose of promoting or remuneration of referrals for products or services that are remunerated by those who pay. The prohibition of referring to health facilities.
3 Primary Laws to Control Health Fraud and Abuse
In addition to creating the status of fraud in criminal health care, lawmakers also created three main laws to regulate the cases of health fraud and abuse:
1. Federal False Claims Act
It imposes civil liability for anyone who deliberately makes or triggers fraud or false assertions to federal authorities.
2. Anti-Kickback Statutes
Targets those who pay, solicit or offer to take remuneration, either intentionally or voluntarily, for the services that are referred to or provided through federal health insurance programs.
3. Physician Self-Referral Law
Providers are prohibited from referring to an organization in which the provider is a shareholder or investment interests, or a reimbursement agreement, also known as Stark Law, for certain health services covered under federal programs for healthcare. Healthcare providers who are in violation of medical fraud law could face sanctions that include exclusion from the program and civil penalties for monetary violations from federal healthcare programs.
Tips to Prevent Healthcare Fraud and Abuse
A strong compliance program is vital to avoid the occurrence of fraud and other abuses in healthcare. The HHS Office of the Inspector General (OIG) said in its official compliance report that the robust compliance program is designed to create a culture in hospitals that encourages the prevention, detection, and resolution of behavior that is not in compliance with the national and federal regulations, and the regulations of the federal, state and private healthcare programs and hospital ethics and business practices.
OIG Recommendations to providers
The OIG also suggested the following elements for providers!
- ACS Primary Care Physicians Billing help hospitals comply with enforcement and combating fraud suspicions, for example, the processing of claims and financial ties with other hospitals (i.e. the conformity with the provisions of assessment of staff)
- Designation of a Chief Compliance Officer and the designation of other Organizational and Monitoring Compliance Personnel and reporting to the Hospital’s governing body.
- The maintenance of a medical-related fraud reporting and complaints process including the creation of a hotline and of security measures for anonymity.
- Establishing a framework to respond to accusations of abuse and fraud in the health sector and implementing disciplinary measures for employees who do not comply with the rules and regulations.
- The use of reviews and audits to monitor enforcement and reduce the risk of problems.
- Remediation and investigation of issues in the system and implementation of policies when employees who are affected are either retained or fired.
Providers are also required to follow the rules and guidelines for compliance with the Office of Inspector General. This applies to health professionals, medical equipment manufacturers, and third-party billers. The reporting, tracking, and billing consistency are able to enhance the credibility and worth of the service. Make sure that any irregularities with regards to Primary Health Billing or coding are identified as quickly as feasible. Take a look at the accounting documentation and compare them to competing providers and the related ones.