Healthcare providers across the country are now being targeted for healthcare fraud investigations. Many of those providers are clueless. They don't even know why they're being investigated. Are Your Actions Causing You to Become a Target for a Healthcare Fraud Investigation?Do you engage in one or more of the following:
Accept what the insurance carrier offers, without question
Work with 3rd- party liability carriers and accept what your patients give you once they receive settlement, and accept your patient's account of settlement negotiations
Allow your patients to retain an attorney to handle 3rd-party liability claims, and you accept the attorney's offer of settlement without question
Work consistently with a limited number of external providers (physicians, surgeons, neurologists)
Fail to read the Explanations of Benefits ("EOBs") in which the insurance carrier identifies the reasons for denial.
Consider peer reviewers' reports as nuisances and as costs of doing business with insurance carriers.
Not bother to read, or don't receive, Controverting Affidavits in which both reasons for denial are reported and aberrant practices are alleged.
Fail to respond to Controverting Affidavits in which reasons for denial are reported.
Fail to respond to Controverting Affidavits in which aberrant practices (unbundling of services, medically unnecessary services, medically unnecessary referrals) are alleged, because you either consider such allegations harmless or you have neither the time nor ability to provide a response challenging such allegations.If the answer is yes, then you need to consider a healthcare compliance program! While you can rationalize to yourself that these issues are just the cost of doing business, a nuisance and can be ignored, the consequences can be disastrous. How to Save Your Practice, License, and Freedom If You Have Become the Target of a Healthcare Fraud Investigation? I've spent decades in practice, and worked closely with insurance carriers, defense attorneys, personal injury attorneys, law enforcement, and others, I understand your fears and concerns. More importantly, I know how to help you gain the knowledge you need to identify the insurance carriers' weaknesses and practice in an ethical manner. I have seen the exodus of hordes of providers due the insurance industry's stranglehold on the healthcare industry, and I have taught many providers to fight back. When investigators come knocking on your office-door, will you be prepared?Here's how you can prepare yourself now:
Develop a healthcare compliance program. Do not make the mistake of believing that a sham compliance program will suffice. You are better off having no compliance program than merely using one for window-dressing. The false sense-of-security often proves disastrous!
Create an audit-response program that effectively addresses deficiencies, both noted and alleged.
Establish a policy for refunds of monies paid in error, when such errors are noted during internal audits.
Develop an effective auditing process, assessing medical necessity and billing issues.
Meet with SIU agents who may have "flagged" your files to identify specific areas of concern.
Develop a Hotline to address issues of concern coming from employees, patients, insurance adjusters, etc.
Attempt to enter into a Corporate Integrity Agreement between the targeted-provider and investigators.
Retain a compliance team knowledgeable in healthcare law. Do not trust your fate to an attorney inexperienced in this arena. Rest assured, the insurance carriers will not! What Are Your Next Steps?Invest in a reputable health care compliance program now. Properly implemented and managed, a Healthcare Compliance Program could make the difference between losing your practice, losing millions of dollars, losing your freedom, and being in a position to proudly announce to healthcare fraud investigators, "Come on in. I would be proud to show you our program."Sham programs create more problems for you than you even want to contemplate. When you become the target of a health care fraud investigation, you do not want to be forced to justify why an unqualified compliance "guru" is helping you in this process.
