One of the most significant challenges for healthcare providers is adhering to a complex set of regulations at local, state, and federal levels. Complying presents challenges for those with a laundry list of responsibilities, including care delivery, payer compliance, billing, and revenue cycle management.
The pressure over profitability can result in providers taking shortcuts. While the intention may not be criminal in nature, the outcome could involve possible serious legal allegations.
The question of criminality
Even the best billing clerks can make mistakes in the favor of the company that employed them. Under pressure, a higher-up may see the error but not correct it in the hopes that no one will notice, and they can pocket the remaining dollars. However, federal government officials committed to the current crackdown are more likely than ever to discover the oversight they may deem criminal in nature.
Comprehensive compliance programs can help not only to prevent but also to detect suspected healthcare fraud and abuse within provider organizations. Without measures, these companies face investigations that could tarnish images and impact revenue streams.
To steer clear of potential problems that can take the form of improper billing practices, providers should know that Medicare and Medicaid officials are not slowing down in their in-depth analysis of claim submissions at a much higher level than before. Scrutinizing claim submissions is occurring more than ever to detect and discourage improper billing practices.
The U.S. Department of Health and Human Services is not holding back in reiterating its focus on fraud and abuse and claims to maintain an ongoing commitment to putting an end to schemes. Their most recent weapon is predictive analytics to put a stop to overbilling proactively. Provider companies would be wise to employ detail-oriented approaches to avoid trouble.