Fighting Allegations of Fraudulent Healthcare Transportation Claims

Fighting Allegations of Fraudulent Healthcare Transportation Claims

Healthcare transportation services have come under increased scrutiny in recent years for potential fraud. With complex regulations and varying interpretations, even well-intentioned providers can find themselves facing allegations. So how does one fight back when accused? This article offers some guidance.

Understanding the Allegations

First, understand exactly what you’re being accused of. Common allegations include:

• Billing for services not provided – Saying you transported a patient when you did not
• Upcoding – Billing at a higher level of service than was rendered
• Kickbacks – Receiving illegal compensation for referrals
• Medically unnecessary trips – Transport lacked medical need

Knowing the specific allegations is critical for mounting your defense. Review the audit carefully and consult experienced legal counsel to fully dissect the issues.

Assembling Your Team

Fighting healthcare fraud allegations is complex; you need an experienced team. Key players typically include:

• Healthcare attorney – Ideally one with subject matter expertise in medical transportation compliance and fraud defense. They will quarterback your legal strategy.
• Compliance officer – Review your documentation and processes to identify any weaknesses being exploited. Suggest corrective actions.
• Medical reviewer – Assess the medical necessity of any claims alleged to be inappropriate. Offer expert testimony on established standards of care.
• Data analyst – Statistical analysis of payment data can reveal flaws in allegations and strengthen appeals.

Choose your team wisely. Their credentials, experience and track record matter greatly.

Conducting an Internal Investigation

After you understand the allegations, conduct your own internal investigation. Analyze a statistically valid random sample of your own records related to the audit period in question. Apply the auditor’s standards, with assistance of your team, to see if similar issues emerge.

An internal probe serves several important purposes:

• Uncovers the scope of problems, if any exist
• Allows self-correction where warranted
• Identifies weaknesses that need addressing
• Provides basis to contest flawed allegations
• Gets you data for appeals

Document your methodology and findings meticulously. You’ll need to present them.

Preparing Your Defense Strategy

Now you’ll work with counsel to build your defense claiming innocence, highlight mitigating factors, and address non-compliance.

If allegations are unfounded – You may be able to get them dismissed outright by presenting clear evidence and explanations. For example, you might show GPS data confirming transports occurred despite billing discrepancies.

If technical errors occurred – You may claim good faith reliance on previous guidance, staff turnover, system glitches, or misunderstandings. While not exonerating, it helps explain how problems arose without ill intent. You still must correct them of course.

If actual compliance issues emerged – Develop a robust corrective action plan. Demonstrate you’re implementing new controls and procedures to fix problems. Argue penalties should be lessened since non-compliance was not purposeful.

Your exact defense angles depend on your specific situation. But in all cases, have sound arguments and evidence backing your positions.

Navigating the Appeals Process

Sadly, initial appeals often fail despite strong cases. But further avenues exist to fight allegations of fraud:

HHS Administrative Law Judge (ALJ) Hearing – ALJs independently review your appeal. Unlike auditors, they make decisions based on current law and have discretion to reduce penalties. Over 75% of ALJ hospital appeals succeed.

Federal District Court – If still unsatisfied, you can take your case to federal court. The burden of proof shifts back to the government rather than you. Courts can dismiss flawed cases outright.

Settlement Negotiations – At any stage, you can attempt negotiating a settlement. If risks or costs of continued appeals seem too high, settling to cut losses may make business sense.

With persistence and evidence, accused providers often mitigate or defeat fraudulent allegations entirely. But it takes understanding the issues, assembling an expert team, conducting thorough internal probes, and crafting an aggressive, multi-pronged defense strategy. The stakes are high, but so are the chances with diligence.

I hope this overview gives you some direction if faced with allegations of healthcare transportation fraud. Let me know if you have any other questions!